Useful documents for you
July 2020 UPDATE
For the Adult [Age 18+] Intake Form: After you make an appointment through our support staff, an email will be sent to you with a link and instructions for completing your intake form online using an automated system from HushMail. You’ll fill out the forms by typing directly into the online form, will apply an electronic signature for authorizations and consents, and the completed form will be securely transmitted back to ACP. Your completing this HushMail form within 24 hours is appreciated. Questions? Call us at 402-334-1122
For all other intake forms and telemedicine consents, go here.
Release of Information – this is the form to use when a set of records is to be sent to [or from] Associated Counseling Professionals.
Coordination of Care – this form is designed to establish a collaborative relationship between your ACP therapist and other healthcare professionals you work with.
Explanation of Services: StopSmoking2014Terry
Plus, these two items, please:
Smoking Questionnaire and
Before you call to make an appointment for smoking cessation – use this resource to review your readiness: Please, take this quiz from WebMD – it will help you assess your readiness to stop smoking and will offer you tips and resources if you are not quite there yet.