Skip to content
Home
About Us
Español
Our Services
Testimonials
Careers
Online Forms
ROI
TH Consent
Client Form
Contact Us
Menu
Home
About Us
Español
Our Services
Testimonials
Careers
Online Forms
ROI
TH Consent
Client Form
Contact Us
set an appointment
Home
About Us
Español
Our Services
Testimonials
Careers
Online Forms
ROI
TH Consent
Client Form
Contact Us
Menu
Home
About Us
Español
Our Services
Testimonials
Careers
Online Forms
ROI
TH Consent
Client Form
Contact Us
Home
About Us
Español
Our Services
Testimonials
Careers
Online Forms
ROI
TH Consent
Client Form
Contact Us
Menu
Home
About Us
Español
Our Services
Testimonials
Careers
Online Forms
ROI
TH Consent
Client Form
Contact Us
Client Form
Download Form
Client Information
Name
First
Last
Soc. Sec #
Date of Birth
MM slash DD slash YYYY
Guardian Name
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
Alternate Phone
Permission to leave a message at any of the above numbers?
Yes
No
Marital Status
Married
Separated
Divorced
Widowed
Single
Employer
Occupation
School
Teacher/Grade
I would like a 24-hour reminder for my appointments
Yes
No Thanks
Call
Text
Email
*If yes, please provide phone# for reminder call or text
Email Address
Emergency Contact
Physician Name
Phone Number
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Medications (Include Dosage)
Primary Insurance
Name of Insured
Relationship to Client
Insured Birth Date
MM slash DD slash YYYY
Insured Soc. Sec. #
Insured Employer
Insurance Co.
Group #
Policy#
Primary Insurance
Name of Insured
Relationship to Client
Insured Birth Date
MM slash DD slash YYYY
Insured Soc. Sec. #
Insured Employer
Insurance Co.
Group #
Policy#
Informed Consent for Counseling
McDowell Counseling & Associates, LLC therapists will not provide treatment to you in which they are not adequately trained in or certified to use. Please refer to our website for a complete list of therapist certifications and services offered.
Confidentiality:
McDowell Counseling & Associates, LLC maintains a strict policy of confidentiality. All services are guided by the licensing laws of the State of Nebraska. I understand that all information I disclose within sessions is confidential and not to be revealed to anyone outside of McDowell Counseling & Associates, LLC with the exception of:
1. When communication of my diagnosis and other clinical information to my insurance company is necessary for payment;
2. When I have given permission for information to be shared with another person;
3. When disclosure is required by law (e.g. when there is reasonable suspicion of abuse of children or adults; when there is a court order)
4. If I am under 19 years of age, my counselor may advise my parent(s) or legal guardian about developments that could significantly affect my health or well-being. In such situation(s), the specific content between my counselor and me will not be discussed, but my overall progress may be discussed in general terms; or
5. When I present an immediate risk of causing serious harm to oneself or another person.
Supervision and Consulting
Supervision is sometimes necessary for the purpose of providing the best possible service. Supervision may be required by your insurance company, office policy and/or licensing requirements. All staff at McDowell Counseling & Associates, LLC are under the supervision of Meredith McDowell LIMHP #1968. At times the supervisor may be consulted about different cases. If your case is discussed with our supervisor it will be done without revealing any identifying information. All supervisors are bound by the same confidentiality standards as your therapist.
Active Participation
Counseling is a mutual, collaborative process. You and your therapist will work together to develop goals for your therapy. You are responsible for making an effort to work on the problems or issues that concern you. Your therapist is committed to helping you in this process.
Risk/Benefits:
No one can guarantee that counseling or counseling services will produce certain results. There can be many benefits to participating in counseling. The benefits vary and can be maximized by active participation, honesty, and consistent attendance. There are also some risks associated with counseling services. The risks vary but can best be managed and minimized through open communication and reporting any changes that occur after or during treatment. There is also the potential for dual relationships, which can be very common in rural settings. A dual relationship is any routine contact that occurs outside of therapy, such as attending the same church. If a dual relationship occurs, it is best to discuss this issue when it occurs to minimize the risk and assess its impact on the therapeutic relationship. Your direct honest feedback can help minimize risk. We can assure you that our counselors will use their professional skills, to the best of their ability, to address any concerns and help manage possible risk.
Appointments:
Services are by appointment only and generally last either 45 or 60 minutes. The frequency of appointments will be determined by you and your therapist.
Cancellations and No Shows:
There is a 24-hour cancellation policy and all appointments not cancelled with 24 hour notice are subject to a late cancellation fee that will not be covered by insurance. There is a no show policy and all appointments that you do not attend without calling to cancel are subject to a no show fee of $40.00 that will not be covered by insurance, and be paid by you, prior to your next appointment.
I agree to pay these fees, if incurred, I am aware that they will not be billed to my insurance company I understand that I cannot be seen by my therapist again until these fees are paid or payment arrangements have been made.acy policy.
I Agree
Fees and Financial Arrangements:
McDowell Counseling & Associates, LLC fees are: $175.00 for the initial appointment and individual sessions are $125.00 (45 minutes) or as reimbursed by insurance. Additional fees for services, if unknown, should be inquired about prior to the appointment. Often we call on your behalf to inquire about insurance benefits. Any information we receive from your insurance is not guarantee of their payment or your financial liability. We ask for payment at the time of service. If this does not work for you, please speak with our Business Manager to make arrangements for a payment plan. Any returned check will be charged a $25.00 fee.
Outstanding balances after 60 days will be assessed a finance charge unless a payment plan has been arranged with the business manager. If no payment is made after 90 days your account will be sent to collections.
I am aware of McDowell Counseling & Associates, LLC's fees for treatment and I agree to pay the remainder of what my insurance does not cover. I agree to be responsible for payment of all services on my behalf or my dependents. I understand that if payment for services is not made, my therapist may stop treatment and my account may be sent to Collections. I understand all services/materials are non-refundable.
I Agree
Electronic Communication (email/texting)
Electronic communication is not a confidential means of communication. You may still choose to communicate electronically with McDowell Counseling & Associates, LLC (as indicated above on preferred contact method) but you must acknowledge the risks
I authorize McDowell Counseling & Associates, LLC to contact me electronically regarding my appointments, as indicated above. I understand that electronic communication (email/text) is not a confidential means of communication.
I Agree
I acknowledge that counseling will not be done electronically(email/text). If I send any informational electronically that is not in regards to scheduling, I understand that my therapist may not correspond immediately.
I Agree
I understand that if I contact my therapist outside of work hours (evenings & weekends) they will not correspond until the following work day.
I Agree
I understand that any electronic correspondence may become part of my client record.
I Agree
I understand that McDowell Counseling & Associates, LLC cannot ensure that electronic messages will be received or be promptly responded to. Therefore in case of emergency, I am encouraged to call Meredith McDowell at 308-708-9379, or 911.
I Agree
Termination:
Also, please be aware of the following conditions in regards to discontinuing therapy. You may be discharged as a client due to:
1. If your therapist believes that they are unable to help you, because of the concerns you present or because their skills or training may not be appropriate to serve you. You will be informed of this fact and referred to another therapist who may meet your needs better.
2. If you have two consecutive "no shows" or same-day cancellations for appointments.
3. If you have not had and/or kept an appointment in our office in 6 consecutive weeks and this is not part of your treatment plan.
4. If you commit an act of violence toward, threaten, or harass any staff member of McDowell Counseling & Associates, LLC, you may be immediately terminated from treatment.
5. If you are terminated from therapy for something other than completing the agreed-upon treatment plan, you will be given contact information for other sources of therapy. However, this is not a guarantee of further treatment.
My signature below acknowledges that I have read, understand and agree to the above statements. I have received McDowell Counseling & Associates, LLC's privacy policies, understand my rights as a client and how my information may be used and disclosed. I understand and authorize supervision of my case, if necessary. I understand that my signature below is consent for treatment with McDowell Counseling & Associates, LLC. I agree to actively participate in my counseling. I understand the risks and benefits associated with counseling and/or other services offered at McDowell Counseling & Associates, LLC. I understand that if I have any questions regarding the above statements, associated risks or my privacy rights, I can talk to my therapist about any questions or contact Meredith McDowell at 308-708-9379
Signature of Client or guardian if minor
Date
MM slash DD slash YYYY
Witness