Play Therapy Omaha | SimplePractice

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Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Name of any additional legal parent/guardian (if applicable)

Additional parent/guardian's phone number (if applicable)

Additional parent/guardian's email (if applicable)

Reason for care

I am seeking services for:

My self My child Other

First and last name of person or child that you are seeking services for (if inquiring about services for a minor or someone else)

Age of person or child you are seeking services for (if other than self)

Date of birth of person who will receive services (if other than self)

What services are you interested in?

Counseling Occupational Therapy Open to the best fit I have questions

Administrative

Please include a brief description of what you are seeking services for and/or any questions you may have

Limited to 600 characters

Referral source

Please let us know how you were referred to Play Therapy Omaha.

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Billing & Payment

Insurance card upload

Upload a photo of your insurance card

If you selected 'yes' for insurance, please indicate which insurance company below. (Ex: BCBS, Medica, etc). **Please note: we are not in-network with Medicaid, but are happy to provide a list of referrals on request.)

If unable to upload, please email a copy of your card ( front & back) to hello@playtherapyomaha.com

Policy holder's full first & last Name

Policy holders phone number

Policy holders date of birth

Policy number on card

Client Preferences

Provider preference

No preference; I'm open to working with the best fit for my needs. I'm open; I have a preferred provider, but am open to finding the best fit for my needs. Preferred provider; I would like to work only with a specific provider.

Name of preferred provider if applicable

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.