Be Kind Counseling Appointment Inquiry Form
Hello! We're happy you found us! If you would like to request an appointment with Be Kind Counseling, please fill out the fields below. Your inquiry is our scheduling team's first priority. We work quickly to get you matched with one of our therapists.
 
Insurance: We accept all Nebraska Medicaid plans, which include Nebraska Total Care, United Healthcare Community Plan and Molina. We also accept commercial insurance plans including: Blue Cross Blue Shield, Anthem, Wellmark, Aetna, Imagine 360, Midlands Choice, Auxiant, GEHA, Firefighter's Union, and Redirect Health. If you don't see your insurance here, feel free to email our insurance specialist at admin@bekindomaha.com to see if it's something we can accept.
Please note: We are unable to take on any new clients with commercial UHC, UMR, or Medica.


Sign in to Google to save your progress. Learn more
Email *
How did you hear about us? *
Phone number *
Client's first, middle, last name (legal name please) 

*
If you are completing this form on behalf of a minor, please list your full name and your relationship to them below. If not applicable, write N/A *
Client's date of birth *
MM
/
DD
/
YYYY
Please list your insurance *
What Is the main reason you are seeking services? (Please provide as much information as possible in order to get matched appropriately) *
Pick Your Ideal Match!
Court, state-ward, custody, or legal involvement? 
We are able to take on a limited number of Child-Parent-Psychotherapy (CPP) cases, and/or state-ward cases. Please indicate below if this applies.
*
Required
Preferred Scheduling Method *
Required
Preferred times and days for appointment ( Please understand that our providers do their best to accommodate your preferred times, but understand that after school and evenings are often limited. In order to be matched with the best fit therapist for your needs, your flexibility with appointment times is helpful in the beginning when we are working to get your appointment set up. Please explain if you have very specific time/day requests, and we will do our best to work with you. *
How ready are you, and/or your child to begin therapy? 

We work very quickly to get you in, and it is very important to be prompt in following through with our process, including completing the electronic consent forms, which you will receive by email from Therapy Portal Access very soon after submitting this form. (PLEASE MAKE SURE TO CHECK YOUR SPAM/JUNK FOLDER IF YOU DO NOT SEE THE EMAIL IN YOUR INBOX)
*
Not Ready
Very Ready!
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Be Kind Counseling.

Does this form look suspicious? Report