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Signature is required

Client Information

Please check if client is:

Student

Adult

First Name

Middle Name

Last Name

Preferred Name

Preferred Language

Birth Gender

Identified Gender

Date of Birth

The date must be greater than or equal to 1/1/1900

Social Security #

Invalid value

Address

City

State

Zip

Primary Phone Type

Primary Phone #

May we call/leave message/text?

Personal Email

OPS Email Address (if applicable)

RESPONSIBLE BILLING PARTY/GUARANTOR

SAME AS CLIENT (If not please complete the following section.)

Yes

Relationship to Client

Name

Gender

Date of Birth

The date must be greater than or equal to 1/1/1900

Social Security #

Invalid value

Address

City

State

Zip

Primary Phone Type

Primary Phone #

Invalid value

May we call/leave message?

Employment Status

Employer

Legal Guardian (Complete if different from Client and/or Responsible Party)

Relationship to Client

Name

Primary Phone Type

Primary Phone #

Invalid value

May we call/leave message?

Emergency Contact

Same as Legal Guardian

Yes

Relationship to Client

Name

Primary Phone #

Invalid value

Demographics

What do you need to be seen for?

Who will be the client

Client Race?

How did you hear about CCP?

Is client a student of OPS Middle or OPS High School

Client will be seen at which CCP School?

Client will be seen at which CCP Community location?

Is the client a Metro Community College Student?

Metro CC student enrollment status

Client to be seen at which Metro campus?

Insurance Information

To complete the intake process: A front and back copy of your insurance cards need to be submitted to MHS.ccp@nmhs.org as soon as possible

Does the client/guardian have an insurance provider?

Primary Insurance Provider?

I have Medicare/Medicare replacement plan and am aware they will not reimburse for services.

Yes

Does the client / guardian have Medicaid?

Medicaid Number

Medicaid Primary or Secondary

Does the client/guardian have a Medicaid Managed Care Plan?

Medicaid Managed Care Policy #

Primary Insurance Information

Insured's Relationship to Client:

Name

Date of Birth

The date must be greater than or equal to 1/1/1900

Social Security #

Invalid value

Address

City

State

Zip Code

Primary Phone #

Invalid value

Employment Status

Employer

Insurance Company Name

Insurance Company Phone #

Invalid value

Group #

Member ID#

Effective Date

The date must be greater than or equal to 1/1/1900

Secondary Insurance Information

Insured's Relationship to Client:

Name

Date of Birth

The date must be greater than or equal to 1/1/1900

Social Security #

Invalid value

Address

City

State

Zip Code

Primary Phone #

Invalid value

Employment Status

Employer

Insurance Company Name

Insurance Company Phone #

Invalid value

Group #

Member ID #

Effective Date

The date must be greater than or equal to 1/1/1900

Methodist Hospital Community Counseling Program Authorization and Consent for Treatment

I, the client, parent and/or legal guardian of

(client/minor's name),hereby give my authorization and consent for and acknowledge the following, for the duration of counseling care.

CONSENT TO COUNSELING CARE

I consent, either on behalf of myself, or on behalf of the minor listed above, to receive counseling care and treatment. I understand the sessions may either be face to face in person or through telehealth. Telehealth sessions will be performed via a HIPAA compliant platform to reduce the risk of privacy violation.

Treatment may include (please check all that apply);

Individual,

Family,

Couples/relational counseling,

Group

I understand the possible psychological risks involved in pyschotherapy and understand psychotherapy is not an exact science and the results cannot be guaranteed. Psychotherapy is often beneficial, but as with any treatment, there are inherent risks. During therapy, the client may discuss personal issues, which may bring to the surface uncomfortable emotions such as anger, guilt, and sadness. Some of the possible benefits are improved personal relationships, reduced feelings of emotional distress and specific problem solving. No promise has been made to me about the results of treatment.

I authorize, either on behalf of myself, or on behalf of the minor listed above to having electronic medical records shared within the Methodist Hospital Community Counseling Program for the purpose of staff training and supervision.

I further authorize Methodist Hospital Community Counseling Program (MHCCP), any insurance company, and/or any other institution or organization to release all information necessary for the completion of insurance forms and to determine benefits payable. A photocopy of this authorization shall be as valid as the original.

I understand I need to provide accurate information about myself and/or the minor listed above to my clinician, so effective treatment will be obtained. I also agree to play an active role in the treatment process.

I understand I have the opportunity to ask questions regarding the risks, benefits, side effects, alternatives of treatment as well as the consequences of noncompliance with treatment. In addition, I understand I will be informed of the staff’s credentials, licensure, experience, professional associations, specialization, and limitations and ask for additional information if needed.

I have read and understand the items above and have received an explanation of this consent form

Interpreter was present for the review of this consent.

Nebraska Methodist Health System Patient Rights and Responsibilities

Please click on the link below to review and read the Patient Rights and Responsibilities

https://bestcare.org/patient-resources/patient-and-visitor-services/patient-rights-and-responsibilities

By signing below, you acknowledge that you have received the Methodist Health System Notice of Privacy Practices. (Note: My signature doesn't indicate that I have read, understood or agree with the Notice, only that it has been provided to me.)

Best Care Employee Assistance Program Notice of Privacy Practices Authorization and Consent for Treatment

Please click on the link below to review and read the Best Care EAP Privacy Notice

http://www.bestcareeap.org/hipaa-privacy

Client Consent Full Name*

Sign Here Using Mouse or Finger/Stylus Use Keyboard

Parent/Guardian Consent Full Name

Sign Here Using Mouse or Finger/Stylus Use Keyboard

Interpreter Full Name

Sign Here Using Mouse or Finger/Stylus Use Keyboard

Submit

Methodist Hospital Community Counseling Program

Client Registration Form

If you are experiencing a suicidal crisis or are in extreme emotional distress, please call 988. If needed, call 911 or go to the nearest emergency room.

If you have questions or need assistance with completing a form, please call our office at (402) 354-6891.