Foster Care and Foster Parent Forms

These forms are for current KVC Nebraska foster parents only and are NOT part of the Outpatient Therapy Intake Paperwork.

• Monthly Foster Home Log
• Foster Parent Training Verification Form

Shared Living Forms

• Shared Living Application

Outpatient Therapy Intake Forms

If you are a new Outpatient Therapy client, please fill out all forms below.* Please call 402-880-4926 if you have questions.

*It is required that the caregiver participating in services call 402-880-4926 to begin services. Filling out these forms alone does not constitute a referral for services.

• Informed Consent (Note: Includes Grievance Policy, Client Rights and Responsibilities, and HIPAA Notice of Privacy Practices.)
• Insurance Form
• Emergency Contact Authorization Form
• PCP Communication Authorization Form
• Telehealth Consent

Outpatient Therapy Assessment Forms

The forms below are for existing patients only, and will be filled out with the therapist. New patients, please disregard these forms. Please call 402-880-4926 if you have questions.

• SDQ 11-17 Parent Report
• SDQ 11-17 Self Report
• SDQ 4-10 Parent Report
• SDQ Adult – CPP Caregivers
• SDQ 2-4 Parent Report
• SCARED Assessment – Parent Version
• SCARED Assessment – Child Version