Substance Use Services Referral Form

Questions marked with a * are required

58%

Contact Information

First Name

Last Name

Email Address

Client First Name:

Client Last Name:

MI:

DOB:

Current Placement: (ex: Home, Foster Home, etc.)

Caregivers: (if applicable)

SSN:

Gender:

Which Omni location is the closest in distance to you to provide services?

Omaha

Lincoln

Race:

Address:

City:

State:

Zip:

Home Phone Number:

Cell Phone Number:

Payment Information:

Payment Source:

Private Insurance

Medicaid

No Insurance/Self Pay