Lets Get Started with A Better Way Therapy (Omaha, NE)

3900 Dakota Avenue Suite 9
So. Sioux City, NE 68776
Phone: 402-813-2235
Fax: 402 502-1282 info@abetterwaytherapy.com

3223 N 169th Street
Omaha, Nebraska 68116
Phone: 402-813-2235
Fax: 402 502-1282 info@abetterwaytherapy.com

Let's Get Started

If you would like to refer a client to "A Better Way" Therapy, please fill out the form below or download and fax or mail PDF.


Referral Date *		Referral Agency
Referred by		Please Specify
Referral Address		Referral Phone

Name of Client Being Referred *
D.O.B.*		Social Security#
Current Placement		Age
Ethnicity		Gender
Address		City
State		Zip Code
Home Phone		Alt. Phone
Medicaid #		Legal Guardian
Mother's Name		Father's Name

Service Requested

Family Situation (Marital Status, Siblings, etc.)
Reason for Referral/Presenting Problem
Prior Treatment Information/Medical History

Billing Information
Private Insurance		If yes, type of Insurance
Primary Policy ID		Cash Pay?
Straight Medicaid?		Magellan?
State Ward?		Provider Service Referral?
Other source of payment?		If yes, please specify: