Contact Us

Use the form to the right to tell us about you or ask us questions.  We'll try and respond promptly.  Thank you for getting in touch.

1620 South 70th Street, Suite 105
Lincoln, NE, 68506
United States

(402) 853-2396

Into Balance is a community for helping people find peace and confidence in a frantic world using mindfulness principles, meditation, movement, and professional counseling. 

Into Balance Forms Page Banner.png

Forms

registration forms for counseling patients

We have arranged things so that you can complete new patient paperwork from your computer or other device and securely submit it directly to your therapist. Please be sure that the form you are completing is tagged with your therapist’s name.  If you prefer to complete paper forms, simply call or email your therapist. We can send you forms to print, complete, sign, and bring with you to your initial appointment. 

New patients must fill out the "New Patient Information", "Acknowledgments & Informed Consent", and "Patient Insurance Information" forms prior to their initial appointment. Filling our these forms will not schedule an initial appointment. You must contact your therapist by phone or email to set this up.

The "Electronic Communications Informed Consent Form" is optional and need only be submitted if you would like to communicate with Into Balance using email, text messaging, or some other form of electronic communication.


Forms for Drew Buss, MS Ed

NEW PATIENT INFORMATION - Drew Buss, MS Ed

Patient Name *
Patient Name
Patient Date of Birth *
Patient Date of Birth
Please indicate whether you are single, married, unmarried but living together, etc. Feel free to describe your relationship as you see fit.
Patient Address *
Patient Address
Patient Phone (preferred) *
Patient Phone (preferred)
Voice Messages OK? *
Text Messages OK? *
Appointment Reminders *
Do you want text message appointment reminders sent to this number? (1 day in advance)
Patient Phone (alternate)
Patient Phone (alternate)
Voice Messages OK?
Text Messages OK?
Appointment Reminders
Do you want text message appointment reminders sent to this number? (1 day in advance)
Appointment Reminders
Do you want email appointment reminders sent to this address (2 days in advance)
Interpreter? *
Would you like or do you need an interpreter to be present for counseling sessions?
If you have a faith tradition, please describe this here. (Enter "none" or "not applicable" if this doesn't apply to you)
If you attend school, please list the school here. (Enter "none" or "not applicable" if this doesn't apply to you)
(Enter "none" or "not applicable" if this doesn't apply to you)
(Enter "none" or "not applicable" if this doesn't apply to you or if you prefer not to share this information)
PCP Office Address *
PCP Office Address
(Enter "none" or "not applicable" if this doesn't apply to you)
PCP Office Phone # *
PCP Office Phone #
(Enter "000 000 0000" if this does not apply to you)
PCP Release of Information *
Would you like us to communicate with your PCP about your counseling sessions and medical appointments? (This is recommended as a way to promote the most effective delivery and coordination of care)
Please list all prescription and over-the-counter medication you take regularly. Include the name of the medication, the dose, the frequency, and the name of the prescribing practitioner. If none, please note "None."
Name of your Prescribing Provider *
Name of your Prescribing Provider
If you take medication to treat emotional or mental health symptoms, please list the prescribing provider's name here. (Enter "none" or "not applicable" if this doesn't apply to you)
Prescribing Provider Release of Information *
Would you like us to communicate with your prescribing provider about your counseling sessions and medical appointments? (This is recommended as a way to promote the most effective delivery and coordination of care)
Prescribing Provider Address *
Prescribing Provider Address
(Enter "none" or "not applicable" if this doesn't apply to you)
Prescribing Provider Phone *
Prescribing Provider Phone
(Enter "000 000 0000" if this doesn't apply to you)
Providing Provider FAX *
Providing Provider FAX
(Enter "000 000 0000" if this doesn't apply to you)
Will you be using insurance? *
Emergency Contact Name (primary) *
Emergency Contact Name (primary)
Please list someone we can contact in case of an emergency
Emergency Contact Phone (primary) *
Emergency Contact Phone (primary)
Emergency Contact Name (secondary)
Emergency Contact Name (secondary)
Emergency Contact Phone (secondary)
Emergency Contact Phone (secondary)
List a second emergency contact if you choose
I certify that... *
Acceptance of Electronic Signature *
Person Completing This Form *
Person Completing This Form
Minors may not fill out this form. It must be completed by the adult patient (19 or older), or in the case of a patient under age 19, by the legal guardian of the patient.
How is the person completing this form related to the patient?
Date of form completion and submission *
Date of form completion and submission

ACKNOWLEDGMENTS & INFORMED CONSENT - Drew Buss, MS Ed

Please click on and read the Practice Orientation and HIPAA Privacy documents.  You will be asked to acknowledge that you have received and read through these in the following form.

Patient Name *
Patient Name
Patient Date of Birth *
Patient Date of Birth
*
*
*
*
*
*
*
*
RECEIPT OF HIPAA PRIVACY DOCUMENT *
RECEIPT OF PRACTICE ORIENTATION DOCUMENT *
INFORMED CONSENT *
Acceptance of Electronic Signature *
Person completing this form *
Person completing this form
Minors may not fill out this form. It must be completed by the adult patient (19 or older), or in the case of a patient under age 19, by the legal guardian of the patient.
Date of form completion and submission *
Date of form completion and submission

PATIENT INSURANCE INFORMATION - Drew Buss, MS Ed

Patient Name *
Patient Name
Patient Date of Birth *
Patient Date of Birth
Name of Insured *
Name of Insured
Who is the primary "owner" of the Insurance Policy?
Insured's Date of Birth *
Insured's Date of Birth
How is the primary insured related to the patient?
Insured's Address *
Insured's Address
Insured's Phone *
Insured's Phone
(from your insurance card)
(from your insurance card)
Other Insurance and Billing Order *
Please select one of the following:
Are there multiple insurance policies? *
Release of Information to Insurance Company *
Authorization of Benefit Assignment *
Acceptance of Electronic Signature *
Person Completing this Form *
Person Completing this Form
Minors may not complete this form. It must be completed by the adult patient (19 or older), or in the case of a patient under age 19, by the legal guardian of the patient.
Please note how the person completing this form is related to the patient
Date of form completion and submission *
Date of form completion and submission

ELECTRONIC COMMUNICATIONS

If you would like to communicate with us electronically (email, texting, etc.) please read the "Electronic Communications Information Form" and then complete and submit the "Patient Electronic Communications Informed Consent" form.  If you have not completed this form, your communication with us at Into Balance will be limited to in-person contact, telephone contact, or the US Mail.


PATIENT ELECTRONIC COMMUNICATIONS INFORMED CONSENT FORM - Drew Buss, MS Ed

Patient Name *
Patient Name
Patient Date of Birth *
Patient Date of Birth
Messaging-Capable Phone *
Messaging-Capable Phone
Enter the phone number that you will use for text messaging (Enter "000 000 0000" if this does not apply to you)
If there are other forms of electronic communications that you wish to use to communicate with us, please make that request and describe the details here (Enter "none" or "not applicable" if this does not apply to you)
*
*
Acceptance of Electronic Signature *
Person Completing This Form *
Person Completing This Form
Minors may not fill out this form. It must be completed by the adult patient (19 or older), or in the case of a patient under the age 19, by the legal guardian of the patient.
Please describe how the person completing this form is related to the patient.
Date of form completion and submission *
Date of form completion and submission

Forms for karen Marker MA

Karen’s Online Forms Are Coming Soon. In the meantime, please download, print, and complete the form below. Then bring the completed form, a picture ID, and your insurance card to your initial appointment.