Gamblers Assistance Program
Compulsive Gambling Helpline: 1-800-522-4700 - 24-Hours / 7 Days a Week

Provider FormTemplates

Click on the links below to get templates of suggested provider forms for the Gamblers Assistance Program. Agencies are encouraged to use these forms as a basis for the clinical records management program required by regulation. These forms are available in MS Word for editing by providers. You may want to customize by these forms by including the providers name or logo or creating local templates on the providers’ electronic systems

• Problem Gambling Client Record Checklist
• Admissions Form
• HIPAA Privacy Notice
• HIPAA Privacy Compliance
• GAP Intake Assessment
• Confidentiality Statement
• Consent to Release
• Client Rights & Responsibility
• Agreement Not To Use
• Progress Notes
• File Audit Sheet
• Gambling Evaluation Report
• South Oaks Gambling Screen
• SOGS Score Sheet
• GA 20 Questions
• DSM-IV Diagnostic Criteria
• Assessment of Strengths & Problems
• Readiness Ruler
• Concerned Person Questionnaire
• Significant Other Report (Collateral Report)
• Planning Assessment Summary
• Treatment Plan
• Discharge Sheet
• Entire set of forms in ONE Zipped download!
  

For more information, contact:

Eric Hunsberger - Program Manager
Nancy Heller - Treatment Coordinator
Abigail Anderson - Staff Assistant I
Gamblers Assistance Program
DHHS-Division of Behavioral Health
P.O. Box 98925
Lincoln, NE 68509-8926
Phone: 402-471-7851
Fax: 402-471-7859

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