top of page

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
Upload Insurance Front
Upload supported file (Max 15MB)
Upload Insurance Back
Upload supported file (Max 15MB)
Upload Identification Front
Upload supported file (Max 15MB)
Secondary Insurance Front
Upload supported file (Max 15MB)
Secondary Insurance Back
Upload supported file (Max 15MB)

This referral form collects personal and health-related information and is submitted electronically to our encrypted email. However, the form itself is not connected to a secure portal. While providing complete information may help us connect you with a therapist more efficiently, please only share what you’re comfortable with at this time. As long as you include a phone number, a member of our team will call you to gather any additional information needed. Please avoid including highly sensitive medical, legal, or diagnostic information on this form.
By submitting this form, you acknowledge and accept the inherent risks associated with electronic communication.

Your information has been submitted. We will be in contact with you shortly.

bottom of page