Provider Referral Form | Behavioral Counseling Solutions Grand Island NE

Referring Provider / Office *

Provider Phone or Email *

Client First Name *

Client Last Name *

Client Phone/Email (for intake) *

Client Date of Birth

Primary Reason for Referral *

General Counseling Addiction / Substance Use Trauma / EMDR Family or Couples CSOTS / Court Ordered Clinical Evaluation

Additional Context / Instructions

If this client is self-paying, you can include their financial info below to check eligibility for our sliding scale program.

Household Size

Annual Household Income

HIPAA Compliance: Our systems protect PHI. Please keep context brief; we conduct a full clinical intake.
Financial Aid: We use an FPL-based sliding scale to ensure services are accessible to all.
Timelines: Referrals are processed within 24-48 business hours.
Court Deadlines: For urgent cases, please call (308) 218-6045.

Professional Referral Form