Forms

Before your initial visit to Gold Circle Counseling LLC, there are forms to fill out. You can either download the editable forms below and open in adobe acrobat to read and edit, print them and fill them out by hand, or come into the office 20 minutes before your session is scheduled to begin to fill out the paperwork. Please bring your insurance card and information.


Dear Valued Client,

Gold Circle Counseling places the people we serve at the center of what we do. The safety of our clients and staff is our foremost concern. Because of the rapidly changing developments and news about the coronavirus and diagnosed cases of COVID-19 in Nebraska, we want to assure you that GCC is taking every precaution to ensure that the services you rely on remain available to you.

Beginning 3/30/2020 we will no longer be seeing clients in person at the office. Your provider will contact you directly to discuss the alternate options for your sessions. This may include telephone and/or video TeleHealth.

In order to proceed with these services, please click on the button below called “TeleHealth Request” send us your Name, Telephone and Email – PLEASE PUT “Telehealth Request” in your subject line. Once we receive that, we will email a secure Telehealth Consent form, or other forms as needed. Please send it back and include your name in the subject line.

Thanks for your patience during this time.

The staff of Gold Circle Counseling LLC

Request TeleHealth Form
Download (pdf) Client Information
Download (pdf) Client Medical Information
Download (pdf) Client Policy
Download (pdf) Consent to Treatment
Download (pdf) Privacy Notice
Download (pdf) Release of Confidential Information
Download (pdf) Financial Policy & Billing Agreement-Therapist
Download (pdf) Financial Policy & Billing Agreement-Prescribers

Forms for Barbara Clinkenbeard

Download (pdf) Clinkenbeard Medication Policies
Download (pdf) Clinkenbeard Financial Policy & Billing Agreement
Download (pdf) Clinkenbeard Privacy Notice