Request an Appointment

Request an Appointment, your first step towards accessing professional counseling services. We understand that seeking support is a significant decision, and we're here to make the process as simple as possible. By filling out the form below, you're taking a proactive step towards prioritizing your mental and emotional well-being. Our team of skilled therapists is eager to connect with you, listen to your concerns, and tailor a plan that aligns with your unique needs and goals. Your journey towards healing and positive change starts here. Please note, if you are a client with our office this submission form should not be used as an alternative to direct communication with your therapist or to cancel or reschedule appointments. If you are in need of assistance, please contact us directly at (308) 251-2222.

If you are experiencing a medical emergency please call 911 or locate the nearest emergency room. If you are having thoughts of suicide or self-harm please contact Richard Young at (308)-865-2000 or contact the Suicide and Crisis Lifeline at 988.

Appointment Form

Today's Date

First & Last Name

Phone

Address

Age

Date of Birth

Is there pending Litigation/Court Proceedings?

Referral Source

Insurance Provider(s) - Please list all polices including primary and secondary

Insurance Primary Policy Holder

Ins Policy Holder DOB

Emergency Contact and Relation

General Availability

Emergency Contact Phone

Please provide a brief summary for the reasoning for seeking counseling

Upload Insurance Front