New Client Referral / Intake Form

Confidential Client Information for Behavioral Counseling Solutions

Provider: Thomas B. Florez, MA, LIMHP, LADC, CSOTS
Practice: Florez Counseling Solutions / Behavioral Counseling Solutions
Location: Kearney, NE 68847 | Phone: (308) 218-6043

1 Client Information

Full Name *

Date of Birth *

Gender

Age

Full Address

Phone Number(s) *

Email Address *

Emergency Contact (Name/Phone/Relationship)

2 Referral Source

Referred By (Name/Agency/Relationship)

Referral Phone/Email

Reason for Referral

3 Presenting Concerns

Primary Concern(s)

Duration of Concern(s)

Any Current Safety Concerns (self-harm, harm to others, abuse, domestic violence, etc.)?

Yes No

If yes, please describe:

4 Personal & Family

Marital Status

Living Arrangements

Do you have children?

Yes No

If yes, please list ages:

5 Medical & Mental Health

Primary Care Physician

Current Medications

Current or Past Mental Health Diagnosis

Previous Counseling/Treatment?

Yes No

If yes, when/where:

6 Substance Use History

Alcohol Use?

Yes No

Details (frequency, amount, etc.):

Drug Use?

Yes No

Details (type, frequency, etc.):

Tobacco Use?

Yes No

Details:

7 Insurance & Payment

Insurance Provider

Policy #

Responsible Party

Self-Pay?

Yes No

Sliding Scale Fee Program

If you are self-paying, you may qualify for reduced rates based on your household size and income. We use the **2024 Federal Poverty Level (FPL)** guidelines as our objective benchmark.

Household Size

Annual Gross Income

Income Verification Tiers (Annual Household Income)

Size	100% FPL	$50 Fee	$75 Fee	$100 Fee	Full Fee

* Note: These are estimated rates. Final fee determination requires income verification during your first session.

8 Administrative

Intake Completed By

Date

Additional Notes

By clicking submit, you acknowledge that this information is being transmitted securely for the purpose of clinical intake.