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5658 N. 103rd st. Omaha, NE 68134
402-571-3995
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Home
Counseling Services
EMDR
Anxiety
Addiction
Anger Management
Depression
Teen Counseling
Couples Counseling
Counselors
Michelle Oczki
Nanon Perdaems-Vigen
Aryn Bowlby-Safranek
Courtney Frerichs
For Clients
Insurance & Fees
New Client Forms
HIPAA Policy
Blog
Contact Us
Home
Counseling Services
EMDR
Anxiety
Addiction
Anger Management
Depression
Teen Counseling
Couples Counseling
Counselors
Michelle Oczki
Nanon Perdaems-Vigen
Aryn Bowlby-Safranek
Courtney Frerichs
For Clients
Insurance & Fees
New Client Forms
HIPAA Policy
Blog
Contact Us
Search for:
Online Intake Form
Michelle Oczki
2019-08-08T08:14:14+00:00
New Client Intake Forms
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Envision Counseling Center, LLC
Name
*
First
Last
Date of Birth
*
Date Format: MM slash DD slash YYYY
Gender
*
Male
Female
Other
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darrussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Home Phone
Work Phone
Cell Phone
*
Is it OK to call and leave a message
*
Yes
No
Email
*
Social Security Number
Who is your current employer?
Relationship Status
*
Never Married
Partnered
Married
Separated
Divorced
Widowed
If partnered or married, what is your partner/spouse's name?
Emergency Contact | Name
*
First
Last
Relationship
*
Phone
*
If the client is younger than 19 years old: Parent/Guardian Name
First
Last
If the parents are divorced: Custodial Parent Name
First
Last
Phone
Is there joint custody?
Yes
No
Primary Care Physician's Name
Phone
Psychiatrist's Name (if applicable)
Phone
Do you have any allergies?
*
Yes
No
If yes, please list (click (+) to add more than one).
Are you currently taking any medications?
*
Yes
No
If yes, please list (click (+) to add more than one).
Insured/Responsible Party Name
Insured/Responsible Party Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darrussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Insured/Responsible Party Phone
Insurance Company
Policy Number
How did you hear about us?
Website
Briefly describe what you would like accomplish in counseling
Acknowledgement
*
I acknowledge entering my name below is equivalent to a handwritten signature.
Client Signature
*
Date
*
MM
DD
YYYY
Privacy
*
By using this form you agree with the storage and handling of your data by this website.
*
Consent to Treatment and Client Rights and Responsibilities
The undersigned requests and agrees to clinical therapy services. These services include but are not limited to: individual, family, couples, conjoint, marital, group and animal assisted counseling. In addition, I grant authority to my therapist to engage in professional consultation and/or emergency telephone responses necessary for my treatment.
If you experience a medical or psychiatric emergency, call 911 or go to your nearest emergency room.
Confidentiality Policy
Envision Counseling Center, LLC will give information to others only with my written consent with exception of the following: The law requires a report to be made if there is reason to believe that a child has been abused, a client threatens to harm him or herself, or another person.
Client Rights:
As a client you have the right to privacy, to be treated with respect, make decisions about your care and treatment plan, get information in a way that you can understand, and refuse treatment that you do not want.
Client Responsibilities:
Clients are responsible for giving us complete information about your health so we can better assist you. Please follow the treatment plan that you develop with your therapist, and attend appointments on time. All unpaid charges are the client’s responsibility.
Consent to Treatment
Acknowledgement
*
I acknowledge entering my name below is equivalent to a handwritten signature.
Name
*
First
Last
Date
*
Date Format: MM slash DD slash YYYY
Financial Agreement and Office Policy Notification
Thank you for choosing Envision Counseling Center, LCC as your service provider. We are pleased to have the opportunity to help you reach your therapeutic goals. In order to better assist you, we have policies in place regarding attendance and services not covered by insurance.
Payment is expected the time of service. This may be your self-pay, co-pay, co-insurance, or deductible amount. If you are unable to pay at time of service, the appointment can be re scheduled.
Please notify us as soon as possible if there are any changes in your insurance or payer coverage, policy number or employment. Failure to do so may result in claim denial. The client or responsible party is responsible for any charges not covered by insurance or third party payers.
There are some services you may want your therapist to provide that are not covered by insurance. These include but are not limited to: sessions held via phone or other non-face to face therapy, duplication of your medical records, court ordered or other legally related services, and other types of therapy or evaluation not covered by your insurance. Please ask your therapist for information on these fees.
Your therapist sets aside a specific appointment time exclusively for you.
We require 24 hours notice for cancellations
. This allows us to serve other individuals that require urgent appointments. We realize that true emergencies do happen, and such cases will be taken into consideration.
Failure to provide 24 hour notification, or no-showing will result in a $25.00 fee to be paid by your next appointment. Three no-shows or late cancellations within a 90 day period will result in termination of services
.
Parents or other care givers must be present in the waiting room with children under 10, and with children that require supervision. Please do not eat in the waiting room.
We request that you silence your cell phones in session and refrain from using them in the waiting room, as this may be disruptive to others. Thank you for your cooperation.
Acknowledgement
*
I acknowledge entering my initials and name below is equivalent to a handwritten signature.
Please initial here to acknowledge your understanding of our late cancellation fee.
*
Name
*
First
Last
Date
*
Date Format: MM slash DD slash YYYY
Assignment of Insurance Benefits and Authorization to Release Information to Payers
I hereby authorize and request my insurance company, EAP, and/or Medicare and Medicaid to make payments directly to Envision Counseling Center, LLC for services rendered. I also authorize Envision Counseling Center, LLC to release any information pertinent to services rendered to any authorized representative ofmy insurance company, EAP and/or Medicare and Medicaid.
Acknowledgement
*
I acknowledge entering my initials and name below is equivalent to a handwritten signature.
Name
*
First
Last
Date
*
Date Format: MM slash DD slash YYYY
I acknowledge that I have been offered a copy of Envision Counseling Center LLC’s Notice of Privacy Practices form.
Acknowledgement
*
I acknowledge entering my initials and name below is equivalent to a handwritten signature.
Name
*
First
Last
Date
*
Date Format: MM slash DD slash YYYY
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