Staff Forms

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0-Credible-Clinical-Workflow-2023-with-addendums-A-G.pdf Credible Clinical Workflow 2023, with addendums A-G.pdf application/pdf

Open Download Copy Link 5.42 MB September 22, 2023
5.42 MB
0-Credible-Office-Manager-Workflow-2023.pdf Credible Office Manager Workflow 2023.pdf application/pdf

Open Download Copy Link 6.89 MB March 7, 2024
6.89 MB
1-Administrative-Staff-Roles-Responsibilities.pdf Administrative Staff Roles Responsibilities.pdf application/pdf

Open Download Copy Link 132.22 KB July 12, 2023
132.22 KB
30-90-Day-Follow-Up-Report-wout-Dx.pdf application/pdf

Open Download Copy Link 14.43 KB April 14, 2023
14.43 KB
30-Day-Follow-Up-Report.pdf application/pdf

Open Download Copy Link 15.09 KB April 14, 2023
15.09 KB
Adult-Adolescent-Discharge-Survey.pdf application/pdf

Open Download Copy Link 15.35 KB April 14, 2023
15.35 KB
Adult-Diagnostic-Interview.pdf application/pdf

Open Download Copy Link 55.83 KB April 14, 2023
55.83 KB
Adult-Medication-Management-Assessment.pdf application/pdf

Open Download Copy Link 54.61 KB April 14, 2023
54.61 KB
Adult-Mental-Health-Assessment.pdf application/pdf

Open Download Copy Link 55.53 KB April 14, 2023
55.53 KB
Adult-Substance-Abuse-Evaluation.pdf application/pdf

Open Download Copy Link 83.3 KB April 14, 2023
83.3 KB
AIMS_Form.pdf application/pdf

Open Download Copy Link 17.08 KB April 14, 2023
17.08 KB
BAM-30-Day-Instrument-11-2021.pdf application/pdf

Open Download Copy Link 574.27 KB April 14, 2023
574.27 KB
Billing-Sheet.pdf Billing Sheet.pdf application/pdf

Open Download Copy Link 100.33 KB April 4, 2024
100.33 KB
CAP-Assessment-Adult.pdf application/pdf

Open Download Copy Link 52.41 KB April 14, 2023
52.41 KB
CAP-Assessment-Youth.pdf application/pdf

Open Download Copy Link 52.62 KB April 14, 2023
52.62 KB
CASI.pdf application/pdf

Open Download Copy Link 7.42 MB April 14, 2023
7.42 MB
CEU-Form-as-of-7-01-2023.pdf CEU Form as of 7-01-2023.pdf application/pdf

Open Download Copy Link 31.73 KB June 30, 2023
31.73 KB
Charge_Entry_Log.pdf application/pdf

Open Download Copy Link 8.69 KB April 14, 2023
8.69 KB
Child-Co-Occurring-Eval.pdf application/pdf

Open Download Copy Link 75.13 KB April 14, 2023
75.13 KB
Child-Diagnostic-Interview.pdf application/pdf

Open Download Copy Link 56.92 KB April 14, 2023
56.92 KB
Child-Medication-Management-Assessment.pdf application/pdf

Open Download Copy Link 53.12 KB April 14, 2023
53.12 KB
Child-Mental-Health-Assessment.pdf application/pdf

Open Download Copy Link 56.28 KB April 14, 2023
56.28 KB
Child-Substance-Abuse-Evaluation.pdf application/pdf

Open Download Copy Link 71.24 KB April 14, 2023
71.24 KB
Client-Percep-of-Care-2019-2020.pdf application/pdf

Open Download Copy Link 48.48 KB April 14, 2023
48.48 KB
Clients-Rights-Agency-Policy-10-2021.pdf application/pdf

Open Download Copy Link 129.32 KB April 14, 2023
129.32 KB
Clients-Rights-Agency-Policy-12-2018-SPANISH.pdf application/pdf

Open Download Copy Link 36.57 KB April 14, 2023
36.57 KB
Co-Occurring-Evaluation.pdf application/pdf

Open Download Copy Link 83.61 KB April 14, 2023
83.61 KB
Community-Support-Assessment.pdf application/pdf

Open Download Copy Link 43.62 KB April 14, 2023
43.62 KB
Community_Support_Annual_Consumer_Report.pdf application/pdf

Open Download Copy Link 16.12 KB April 14, 2023
16.12 KB
Community_Support_Consumer_Crisis_Plan.pdf application/pdf

Open Download Copy Link 13.82 KB April 14, 2023
13.82 KB
Consent_for_Observation.pdf application/pdf

Open Download Copy Link 7.61 KB April 14, 2023
7.61 KB
Consultants_Worksheet.pdf application/pdf

Open Download Copy Link 20 KB April 14, 2023
20 KB
Contact_Note.pdf application/pdf

Open Download Copy Link 10.62 KB April 14, 2023
10.62 KB
Contracted-Services-billing-form.pdf Contracted Services billing form.pdf application/pdf

Open Download Copy Link 17.9 KB May 25, 2021
17.9 KB
Crisis_Log.pdf application/pdf

Open Download Copy Link 9.67 KB April 14, 2023
9.67 KB
Crisis_Response_Form.pdf application/pdf

Open Download Copy Link 11.34 KB April 14, 2023
11.34 KB
CS-Flex-Funds-Reimbursement-Request-Form.pdf application/pdf

Open Download Copy Link 650.25 KB April 14, 2023
650.25 KB
CS-Mileage-Sheet-as-of-7-01-2023.pdf CS Mileage Sheet as of 7-01-2023.pdf application/pdf

Open Download Copy Link 30.02 KB June 30, 2023
30.02 KB
CS-Referral-Form-2019.pdf application/pdf

Open Download Copy Link 32.2 KB April 14, 2023
32.2 KB
Denial_of_patient_request_to_access_records.pdf application/pdf

Open Download Copy Link 40.82 KB April 14, 2023
40.82 KB
Denial_of_pt__request_to_amend_records.pdf application/pdf

Open Download Copy Link 41.83 KB April 14, 2023
41.83 KB
Disclosure_Log.pdf application/pdf

Open Download Copy Link 12.09 KB April 14, 2023
12.09 KB
EMDR_Consent.pdf application/pdf

Open Download Copy Link 14.29 KB April 14, 2023
14.29 KB
Employee-Handbook-2023.pdf Employee Handbook, 2023.pdf application/pdf

Open Download Copy Link 515.04 KB January 22, 2024
515.04 KB
Fax-sheet-2020-logo.pdf application/pdf

Open Download Copy Link 152.89 KB April 14, 2023
152.89 KB
FC_Referral_Form_to_Community_Medical_Center.pdf application/pdf

Open Download Copy Link 22.35 KB April 14, 2023
22.35 KB
Financial-Policy-client-5-2023.pdf Financial Policy, 5-2023.pdf application/pdf

Open Download Copy Link 374.69 KB June 12, 2023
374.69 KB
Financial-Policy-SPANISH-8-2022.pdf application/pdf

Open Download Copy Link 13.74 KB April 14, 2023
13.74 KB
Flex_Spending_Account_Claim_Form-Employee.pdf application/pdf

Open Download Copy Link 15.38 KB April 14, 2023
15.38 KB
Full-Fee-Cheat-Sheet-eff-8-2023.pdf Full Fee Cheat Sheet, eff 8-2023.pdf application/pdf

Open Download Copy Link 116.13 KB July 28, 2023
116.13 KB
Grievance-Policy-11-2020-SPANISH.pdf application/pdf

Open Download Copy Link 50.59 KB April 14, 2023
50.59 KB
Grievance-Policy-11-2020.pdf application/pdf

Open Download Copy Link 5.11 KB April 14, 2023
5.11 KB
Group_Progress_Note.pdf application/pdf

Open Download Copy Link 40.77 KB April 14, 2023
40.77 KB
Guest_speaker_agreement_form.pdf application/pdf

Open Download Copy Link 11.1 KB April 14, 2023
11.1 KB
Hardship_Form.pdf application/pdf

Open Download Copy Link 17.49 KB April 14, 2023
17.49 KB
Healthy-Blue-IOP-Auth-request-form.pdf application/pdf

Open Download Copy Link 1021.52 KB April 14, 2023
1021.52 KB
Healthy-Blue-Psych-Testing-Auth-request-form.pdf application/pdf

Open Download Copy Link 809.14 KB April 14, 2023
809.14 KB
History_of_non-routine_disclosures_request.pdf application/pdf

Open Download Copy Link 29.67 KB April 14, 2023
29.67 KB
Incident-Report-Form-10-2021.pdf application/pdf

Open Download Copy Link 720.52 KB April 14, 2023
720.52 KB
Injectable_Order_Form.pdf application/pdf

Open Download Copy Link 34.21 KB April 14, 2023
34.21 KB
Interpretive_services_agreement_form.pdf application/pdf

Open Download Copy Link 42.79 KB April 14, 2023
42.79 KB
IOP-OP-Agreement-Form-3-2019.pdf application/pdf

Open Download Copy Link 45.33 KB April 14, 2023
45.33 KB
IOP-OP_sign_in_sheet.pdf application/pdf

Open Download Copy Link 9.09 KB April 14, 2023
9.09 KB
Laboratory-Requisition-Form.pdf application/pdf

Open Download Copy Link 13.35 KB April 14, 2023
13.35 KB
Lincoln_CS_flex_funds.pdf application/pdf

Open Download Copy Link 20.96 KB April 14, 2023
20.96 KB
LPS-Mileage-Form-7-01-2023.pdf LPS Mileage Form, 7-01-2023.pdf application/pdf

Open Download Copy Link 30.7 KB June 30, 2023
30.7 KB
LPS-Timesheet-8-2023-Fillable.doc LPS Timesheet, 8-2023 (Fillable).doc application/msword

Download Copy Link 52.5 KB August 2, 2023
52.5 KB
Med-Contact-Note-5-2019.pdf application/pdf

Open Download Copy Link 87.05 KB April 14, 2023
87.05 KB
Med-Error-Note-8-2022.pdf application/pdf

Open Download Copy Link 86.47 KB April 14, 2023
86.47 KB
Medication-Management-Progress-Note.pdf application/pdf

Open Download Copy Link 43.6 KB April 14, 2023
43.6 KB
Medication-Notice-SPANISH.pdf application/pdf

Open Download Copy Link 288.17 KB April 14, 2023
288.17 KB
Medication_Injection_Note.pdf application/pdf

Open Download Copy Link 27.91 KB April 14, 2023
27.91 KB
Medication_Removed_for_Disposal_Form.pdf application/pdf

Open Download Copy Link 16.17 KB April 14, 2023
16.17 KB
MHB_Commit_90_d_wout_Dx.pdf application/pdf

Open Download Copy Link 21.82 KB April 14, 2023
21.82 KB
Mileage-Sheet-as-of-7-01-2023.pdf Mileage Sheet as of 7-01-2023.pdf application/pdf

Open Download Copy Link 29.64 KB June 30, 2023
29.64 KB
MM-Appointment-Reminder-Card-7_2023.pdf MM Appointment Reminder Card 7.2023.pdf application/pdf

Open Download Copy Link 120.48 KB November 3, 2023
120.48 KB
MM-Client-Distribution-Log-3-2022.pdf application/pdf

Open Download Copy Link 283.65 KB April 14, 2023
283.65 KB
MM-Consent-to-Give-Written-Prescriptions-to-Designee-3-2022.pdf application/pdf

Open Download Copy Link 99.62 KB April 14, 2023
99.62 KB
MM-Medication-Notice-6-2023.pdf MM Medication Notice, 6-2023.pdf application/pdf

Open Download Copy Link 288.7 KB June 27, 2023
288.7 KB
MM-Optional-Medication-Consent-Form-4-2022.pdf application/pdf

Open Download Copy Link 271.54 KB April 14, 2023
271.54 KB
MM_Symptom_Evaluation_Form.pdf application/pdf

Open Download Copy Link 14.47 KB April 14, 2023
14.47 KB
MSPQ-Medicare-Secondary-Payor-Questionnaire.pdf application/pdf

Open Download Copy Link 604.27 KB April 14, 2023
604.27 KB
NDBH-Consent-SPANISH.pdf application/pdf

Open Download Copy Link 14.41 KB April 14, 2023
14.41 KB
NDBH_Consent.pdf application/pdf

Open Download Copy Link 14.33 KB April 14, 2023
14.33 KB
NTC-Psychological-Testing-Request-Form.pdf application/pdf

Open Download Copy Link 446.19 KB April 14, 2023
446.19 KB
NTC_IOP-Day_Treatment_Authorization_Form.pdf application/pdf

Open Download Copy Link 181.36 KB April 14, 2023
181.36 KB
OQ-45-SPANISH.pdf application/pdf

Open Download Copy Link 418.02 KB April 14, 2023
418.02 KB
OQ-45_2.pdf application/pdf

Open Download Copy Link 39.22 KB April 14, 2023
39.22 KB
Patient-Records-Access-Request-Form-SPANISH.pdf application/pdf

Open Download Copy Link 279.81 KB April 14, 2023
279.81 KB
Patient-Records-Access-Request-Form.pdf application/pdf

Open Download Copy Link 17.44 KB April 14, 2023
17.44 KB
Patient_Assistance_Tracking_Form.pdf application/pdf

Open Download Copy Link 12.94 KB April 14, 2023
12.94 KB
Patient_request_to_amend_records.pdf application/pdf

Open Download Copy Link 41.98 KB April 14, 2023
41.98 KB
Petty_Cash_Reimbursment_Record.pdf application/pdf

Open Download Copy Link 7.64 KB April 14, 2023
7.64 KB
Privacy-notice-2-pg-11-2018.pdf application/pdf

Open Download Copy Link 224.89 KB April 14, 2023
224.89 KB
Privacy-notice-Full-Version-11-2018.pdf application/pdf

Open Download Copy Link 397.52 KB April 14, 2023
397.52 KB
Privacy-notice-in-SPANISH.pdf application/pdf

Open Download Copy Link 338.48 KB April 14, 2023
338.48 KB
Progress-Note.pdf application/pdf

Open Download Copy Link 36.06 KB April 14, 2023
36.06 KB
Psychological-Evaluation.pdf application/pdf

Open Download Copy Link 83.74 KB April 14, 2023
83.74 KB
Purchase_Requisition.pdf application/pdf

Open Download Copy Link 20.37 KB April 14, 2023
20.37 KB
Receipt-Log-Cash-Check.pdf Receipt Log- Cash & Check.pdf application/pdf

Open Download Copy Link 488.9 KB February 20, 2024
488.9 KB
Receipt-Log-Credit-Card.pdf Receipt Log- Credit Card.pdf application/pdf

Open Download Copy Link 485.69 KB February 20, 2024
485.69 KB
Registration-Consent-5-2023.pdf Registration Consent 5-2023.pdf application/pdf

Open Download Copy Link 603.44 KB November 9, 2023
603.44 KB
Registration-Consent-SPANISH.pdf application/pdf

Open Download Copy Link 283.47 KB April 14, 2023
283.47 KB
Registration-Form-2-2023.pdf Registration Form 2-2023.pdf application/pdf

Open Download Copy Link 218.87 KB June 12, 2023
218.87 KB
Registration-Form-SPANISH.pdf application/pdf

Open Download Copy Link 150.23 KB April 14, 2023
150.23 KB
Report-of-Complaint-Rev-5-2018.pdf application/pdf

Open Download Copy Link 12.32 KB April 14, 2023
12.32 KB
ROI-Disclose-Crete-2018-SPANISH.pdf application/pdf

Open Download Copy Link 27.63 KB April 14, 2023
27.63 KB
ROI-Obtain-Crete-2018-SPANISH.pdf application/pdf

Open Download Copy Link 28.09 KB April 14, 2023
28.09 KB
ROI-ObtainDisclose-Auburn-2023.pdf ROI (Obtain+Disclose)- Auburn, 2023.pdf application/pdf

Open Download Copy Link 273.64 KB November 3, 2023
273.64 KB
ROI-ObtainDisclose-Beatrice-2023.pdf ROI (Obtain+Disclose)- Beatrice, 2023.pdf application/pdf

Open Download Copy Link 273.96 KB November 3, 2023
273.96 KB
ROI-ObtainDisclose-Crete-2023.pdf ROI (Obtain+Disclose)- Crete, 2023.pdf application/pdf

Open Download Copy Link 273.65 KB November 3, 2023
273.65 KB
ROI-ObtainDisclose-David-City-2023.pdf ROI (Obtain+Disclose)- David City, 2023.pdf application/pdf

Open Download Copy Link 274.2 KB November 3, 2023
274.2 KB
ROI-ObtainDisclose-Fairbury-2023.pdf ROI (Obtain+Disclose)- Fairbury, 2023.pdf application/pdf

Open Download Copy Link 275.1 KB November 3, 2023
275.1 KB
ROI-ObtainDisclose-Falls-City-2023.pdf ROI (Obtain+Disclose)- Falls City, 2023.pdf application/pdf

Open Download Copy Link 274.57 KB November 3, 2023
274.57 KB
ROI-ObtainDisclose-Lincoln-2023.pdf ROI (Obtain+Disclose)- Lincoln, 2023.pdf application/pdf

Open Download Copy Link 274.55 KB November 3, 2023
274.55 KB
ROI-ObtainDisclose-NE-City-2023.pdf ROI (Obtain+Disclose)- NE City, 2023.pdf application/pdf

Open Download Copy Link 274.58 KB November 3, 2023
274.58 KB
ROI-ObtainDisclose-Seward-2023.pdf ROI (Obtain+Disclose)- Seward, 2023.pdf application/pdf

Open Download Copy Link 274.57 KB November 3, 2023
274.57 KB
ROI-ObtainDisclose-Wahoo-2023.pdf ROI (Obtain+Disclose)- Wahoo, 2023.pdf application/pdf

Open Download Copy Link 273.65 KB November 3, 2023
273.65 KB
ROI-ObtainDisclose-York-2023.pdf ROI (Obtain+Disclose)- York, 2023.pdf application/pdf

Open Download Copy Link 272.97 KB November 3, 2023
272.97 KB
Sample_Log_Form.pdf application/pdf

Open Download Copy Link 58.41 KB April 14, 2023
58.41 KB
SAVE_Verification_Request_Form.pdf application/pdf

Open Download Copy Link 28.94 KB April 14, 2023
28.94 KB
SA_ED_Class_Registration_Form.pdf application/pdf

Open Download Copy Link 16.14 KB April 14, 2023
16.14 KB
SA_Voucher_Tracking_Form.pdf application/pdf

Open Download Copy Link 19.32 KB April 14, 2023
19.32 KB
Service-Note-CS-Goals-and-Objectives.pdf application/pdf

Open Download Copy Link 35.88 KB April 14, 2023
35.88 KB
Service-Note.pdf application/pdf

Open Download Copy Link 32.48 KB April 14, 2023
32.48 KB
Simple-File-List.pdf application/pdf

Open Download Copy Link 1.11 MB April 14, 2023
1.11 MB
Sliding-Fee-Eligibility-Form-effective-8-2023-SPANISH.pdf Sliding Fee Eligibility Form effective 8-2023 (SPANISH).pdf application/pdf

Open Download Copy Link 20.82 KB June 30, 2023
20.82 KB
Sliding-Fee-Eligibility-Form-effective-8-2023.pdf Sliding Fee Eligibility Form, effective 8-2023.pdf application/pdf

Open Download Copy Link 107.63 KB July 11, 2023
107.63 KB
Sliding-Fee-Memo-to-Finance-Director-10-2021.pdf application/pdf

Open Download Copy Link 502.66 KB April 14, 2023
502.66 KB
Sliding_Fee-CDS_Admission_Form.pdf application/pdf

Open Download Copy Link 33.28 KB April 14, 2023
33.28 KB
Sliding_Fee-Discharge-Summary_Form.pdf application/pdf

Open Download Copy Link 15.16 KB April 14, 2023
15.16 KB
SOQ_.pdf application/pdf

Open Download Copy Link 26.52 KB April 14, 2023
26.52 KB
SOQ_Spanish.pdf application/pdf

Open Download Copy Link 38.26 KB April 14, 2023
38.26 KB
Supervisory_Contact_Note.pdf application/pdf

Open Download Copy Link 11.74 KB April 14, 2023
11.74 KB
TASC_Program_Referral_Form.pdf application/pdf

Open Download Copy Link 64.2 KB April 14, 2023
64.2 KB
Telehealth-Consent-SPANISH.pdf application/pdf

Open Download Copy Link 294.73 KB April 14, 2023
294.73 KB
Telehealth_Consent-NEW.pdf application/pdf

Open Download Copy Link 501.53 KB April 14, 2023
501.53 KB
Telehealth_Patient_Satisfaction_Survey.pdf application/pdf

Open Download Copy Link 8.46 KB April 14, 2023
8.46 KB
Time-Off-Form-3-2021-Fillable.pdf application/pdf

Open Download Copy Link 151.8 KB April 14, 2023
151.8 KB
Timesheet-3-2021-Fillable.doc application/msword

Download Copy Link 47.5 KB April 14, 2023
47.5 KB
Transportation_Consent.pdf application/pdf

Open Download Copy Link 10.86 KB April 14, 2023
10.86 KB
Treatment-Plan-Review.pdf application/pdf

Open Download Copy Link 19.34 KB April 14, 2023
19.34 KB
Updated-SA-Service-Note-Adult.pdf application/pdf

Open Download Copy Link 43.05 KB April 14, 2023
43.05 KB
Updated-SA-Service-Note-Child.pdf application/pdf

Open Download Copy Link 37.58 KB April 14, 2023
37.58 KB
Video-filming-release-5-2022.pdf application/pdf

Open Download Copy Link 109.09 KB April 14, 2023
109.09 KB
Voter-Registration-Form.pdf application/pdf

Open Download Copy Link 74.9 KB April 14, 2023
74.9 KB
Waiting-List.pdf application/pdf

Open Download Copy Link 16.36 KB April 14, 2023
16.36 KB
Waiver_of_Liability_Statement.pdf application/pdf

Open Download Copy Link 10.08 KB April 14, 2023
10.08 KB
Weekly_Probation-Parole_Note.pdf application/pdf

Open Download Copy Link 6.98 KB April 14, 2023
6.98 KB
YAP-Assessment.pdf application/pdf

Open Download Copy Link 33.41 KB April 14, 2023
33.41 KB
YAP-Behavioral-Health-Checklist-10-2019.pdf application/pdf

Open Download Copy Link 126.45 KB April 14, 2023
126.45 KB
YAP-Demographic-Form-07-2019.pdf application/pdf

Open Download Copy Link 91.68 KB April 14, 2023
91.68 KB
YAP-Permission-Consent-Form-07-2019.pdf application/pdf

Open Download Copy Link 17.19 KB April 14, 2023
17.19 KB
YOQ-30-PR.pdf application/pdf

Open Download Copy Link 111.26 KB April 14, 2023
111.26 KB
YOQ-30-Spanish.pdf application/pdf

Open Download Copy Link 91.03 KB April 14, 2023
91.03 KB
YOQ-30SR.pdf application/pdf

Open Download Copy Link 31.8 KB April 14, 2023
31.8 KB
ZOOM-Provider-Instructions-using-Individual-Account.pdf application/pdf

Open Download Copy Link 297.04 KB April 14, 2023
297.04 KB
ZOOM-Tips-for-Home-based-Telehealth.pdf application/pdf

Open Download Copy Link 299.96 KB April 14, 2023
299.96 KB

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