INTAKE FORM

Please provide the following information and answer the questions below. Please Note: Information you provide here is protected as confidential information. Please fill out this form prior to your first session.

Name *

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DOB

Age & Gender

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Address

City

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Phone

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May we leave a massage?

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Email *

Please note: Email Correspondence is not considered a confidential medium of communication.

May we send emails

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Referred by (if any

Marital status

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Please list children and ages

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Please list children and ages 2

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Please list children and ages 3

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Emergency Contact

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Emergency Contact 2

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Emergency Contact 3

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Emergency Contact Phone 3

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Insurance Information

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Subscriber

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ABOUT US

At Complete Behavioral Health, we offer comprehensive solutions for a wide variety of mental health issues, addiction, eating disorders, and self-harm. All of our programs are confidential and customized to meet your individual needs. Our goal is to help you lead a healthy and happy life.

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CONTACT US

Omaha Phone: 402-590-2947
Papillion Phone: 402-614-0175
Fax: 402 590-2030
Email: [email protected]
Address: 4565 South 133rd Street Omaha, NE 68137

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Complete Behavioral Health (CBH) may suggest tools and resources on its website that offer information, do-it-yourself tools, and/or ways to connect with others. It does not represent its results as an exhaustive list of all services available to a given individual for a given behavioral health problem, or as an endorsement of specific treatments or services, or as a replacement for treatment or services as performed directly by our qualified providers.

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