DHHS Internet Website - Behavioral Health

Gamblers Assistance Program

Providers Forms & Templates

Problem Gambling Helpline: 1-800-GAMBLER (1-800-426-2537) - 24-Hours / 7 Days a Week

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  GAP Treatment Provider Manual FY2012-13

 GAP Funding Request Form FY13 - must be submitted 14 business prior to the date of a State Committee on Problem Gambling Meeting. The State Committee on Problem Gambling meets quarterly per year in Lincoln, Nebraska.

  Magellan Behavioral Health GAP Provider Manual & Web User Guide 2010

Magellan Behavioral Health Website: www.magellanprovider.com

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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

Agency Based Forms:

• Admission Form
• Consumer’s Rights and Responsibilities
• Confidentiality Statement
• HIPAA Privacy Act Notice
• Consent to Release Confidential Information
• Problem Gambling Consumer Record Checklist
• File Audit Sheet
• Citizenship Attestation Form

Clinical Forms-Tools:

• Intake Assessment (Magellan Form)
• Gambling Evaluation Report
• DSM IV Criteria
• South Oaks Gambling Screen (SOGS) ( www.longislandhome.org)
• SOGS Score Sheet
• GA 20 Questions
• Agreement Not to Use
• Concerned Person Questionnaire
• Significant Other Evaluation
• Consumer Assessment of Strengths and Needs
• Readiness Ruler
• Planning Assessment Summary
• Treatment Plan
• Consumer Progress Note
• Program Discharge Summary (Magellan Form)
  

For more information, contact:

Maya Chilese - Program Manager

Gamblers Assistance Program

DHHS-Division of Behavioral Health

P.O. Box 95026

Lincoln, NE 68509-5026

Phone: 402-471-7792

Fax: 402-471-7859

 

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