Before your initial visit to Gold Circle Counseling LLC, there are forms to fill out. You can either download the editable forms below, print them and fill them out or come into the office 20 minutes before your session is scheduled to complete the paperwork. The other option is to access the electronic forms via email as the provider or receptionist can email you the forms after the initial phone call to the office.

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 4/1/2021 we offer in person and Telehealth session. Please discuss the options with your provider. Your provider will contact you directly to discuss the alternate options for your sessions. This may include telephone and/or video TeleHealth.

If you are a new client requesting Telehealth 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 Services
Download (pdf) Client Information
Download (pdf) Intake Questionnaire
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