Inner Reflections Counseling Center
Client Information
You have taken a very positive step by deciding to seek counseling. We are happy that you have chosen Inner Reflections Counseling Center to assist you on your journey.
Here you will find the paperwork needed for your initial session, along with other helpful documents for current clients. You can print off intake paperwork and fill it out in advance, or you will be asked to fill out the paperwork at your first appointment. Please note, we support family and partners being supportive of their loved one getting help. However, for confidentiality and privacy, thank you for understanding if we are unable to return calls or disclose information for patients 18 years of age or older.
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Telehealth (may also be referred to as electronic) is also an option for services. Many insurances, including Managed Care (Medicaid and/or Medicare), or commercial policies do not cover emergency or crisis telehealth services. Please refer to the member handbook and/or provider handbook for your policy as information may vary. If you are interested in Telehealth services, please download the Telehelath consent form with crisis/safety plan guide:
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What to expect on the Initial Session - Update 2024
Many insurance companies (Payers) require an Assessment at your first session. These may also be referred to as an Initial Diagnostic Interview or intake assessment. Payers have specific requirements we must follow. Here at IRCC we understand that you may not be ready to disclose certain information at your first appointment. We attempt to balance payer requirements in a trauma-informed and culturally sensitive framework. We believe there should be no barriers or conditions to receiving behavioral health and/or substance use treatment or support. When benefits are used, how care is available and delivered, including treatment modality and medical necessity requirements is determined by the payer.
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When utilizing insurance or benefits, treatment and care is limited to guidelines and insurance practices, where guides and practices may not always be clear or found in member or provider handbooks. Payer policies and guidelines may have specific requirements that affect provider ability to balance your wishes and have specific requirements or conditions that you consented to with your plan when you signed up (check with your plan beneficiary/member handbook).
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Insurance will not cover services unless they meet "medical necessity" and program guidelines as defined by your plan. ​ This includes not covering services such as services that are supportive in nature or maintenance care and do require discharge planning on day one.
Please know that we will do our best to support you.
Confidentiality, Privacy and Informed Consent
Your confidentiality and privacy is important to us. The law protects the relationship between a client and a therapist, and information cannot be disclosed without written permission unless legally required.
Exceptions include, but might not be limited to:
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Child abuse or dependent adult or elder abuse, that fall under mandatory reporting to report this to the appropriate authorities immediately.
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Note: if you have knowledge yourself of abuse or neglect and report this to your therapist secondarily, IRCC will encourage you to take the steps to report yourself. If you chose not to, IRCC may report as a secondary party and provide your contact information, as the agency and/or its therapists would not have the necessary details or identifiable information that the appropriate authority may need.
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If a client is threatening serious bodily harm or death, where intent and means are present, to another person, I must notify the police and inform the intended victim.
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If a client intends to harm himself or herself, reasonable efforts will be made to enlist cooperation in ensuring their safety. If they do not cooperate, further measures without permission that are provided by law in order to ensure safety will be taken.
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Notification: We may notify family members or others responsible for your care in emergencies, providing only necessary health information.
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Specialized Government, Court Orders, Public Health, Mandatory Reporting, Duty to Warn, Workers Compensation, Health Oversight, Law Enforcement: Disclosures are made as required or permitted by law.
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Every person in Nebraska who has reasonable cause to believe a child has been subjected to abuse or neglect is a mandatory reporter. If you know of a child or vulnerable adult being abused or Neglected, we encourage you to call and report it to
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National Hotline: 1-800-4-A-CHILD (1-800-422-4453).
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Nebraska Specific Hotline: 1-800-652-1999.
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Colorado Specific Hotline: 1-844-CO-4-KIDS.
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Online Reporting (NE): neabusehotline-dhhs.ne.gov.
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APS hotline (800) 652-1999
When reporting When calling, be prepared to provide the victim's name, age, address, and the reasons for your concern, including descriptions of physical injuries or signs of neglect.​
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IRCC does not have hospital admitting privileges nor do we have the authority to get insurance authorization for services that do not fall under our practice including but not limited to: IOP, inpatient, or partial care. If you care involves a higher level of care you will be directed to the facility or your insurance for admittance and billing questions.
Informed Consent: We need to obtain consent to receive therapy prior to conducting your first session. This will also cover dual relationships and privacy.
For more information please consult the Confidentiality and Privacy Policy below and the Informed Consent, Office Policies and General Information Agreement for Psychotherapy Services or Informed Consent for Psychotherapy.
Informed Consent, Office Policies and General Information Agreement
Other information
Mental Health Advanced Directives - Note, Inner Reflections, it's employees, associates, affiliates, or contracted laborers are not legal experts. We require all legal questions to be directed to those licensed and customary to answer/work with the legal aspects. The link offered redirects to a Nebraska DHHS resource managed by dhhs.ne.gov.
Voter Registration - Note, Inner Reflections, it's employees, associates, affiliates, or contracted laborers are not experts with voting or voting rights. If you do have questions you are encouraged to contact your local county or government office, or community support agency.
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Note: please contact the agency for the latest forms, rates and consent
New Client Paperwork
Note: the link for paperwork is not live at this time, but will be soon. We appreciate your patience.
Intake
Consent for Treatment and HIPAA; Legal and letter/supportive documentation
Adult Assessment History
Assessment History Minor
Therapy Goals
PCP Release
General Release
Safety/Crisis Plan Adult
Financial Agreement
Attendance
Dass21Scale
PHQ-9 and GAD-7
Trauma Screening
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Self-Pay
We recognize that some individuals may not be seeking therapy restricted to Payer or State driven definitions of Medical Necessity, or seeing services such as supportive or maintenance that may not be covered. For this reason we have developed a program that is truly client-centered. You develop the goals and destination, and the provider you are paired with will help you with the coordinates along the way. Unlined managed care, this care can be supportive in nature or maintenance of gains made. We do not bill your insurance for this intervention as insurance requires specific documentation and does restrict modality and interventions whereas this service does not. Payment is due at the date of session. Please see your therapist for more information on the No Surprises Act.