Counseling Common Forms
For assistance please call: 402-488-7400
Patient Demographic Form
Please fill out Patient Information, Contacts, Guarantor Information, Insurance Information, and Sign/Date HIPAA Acknowledgement.
Counseling Informed Consent
Informed consent is the process where an individual voluntarily agrees after being fully informed of the risks, benefits, and alternatives.
Telehealth Informed Consent
Telehealth informed consent explains what to expect when receiving counseling services remotely via video or phone, including privacy and confidentiality considerations, technology requirements, and procedures for emergencies during a virtual session.
Adult History Form
Share your personal, family, medical, and mental health background with your counselor. This helps your counselor understand your needs and make the most of your first session.
Child & Adolescent History Form
Share your child's personal, family, medical, and mental health background with their counselor. This helps their counselor understand their needs and make the most of their first session.
Records Transfer Request
Please fill out to request your records from a previous clinic to be transferred to Lincoln Family Medical Group.
Patients Intake Form - Couples
Print and fill out if you are a new patient as a couple.
HIPAA Privacy Notice
Detailed information about how we protect your privacy.
If you have files to be uploaded to our Medical Records department please click the button below.
PauBox Secure File Upload