We will need some information in order to help you, your child, or your loved one. Well need information on a REGISTRATION FORM, such as name, address, birthday, insurance. Well need a HISTORY so we know enough about the problem to get therapy off to a good start.
Youll be pleased to know that state and federal laws govern how Psychotherapy is delivered. For instance, we observe a high level of confidentiality. This is explained in the brochure, Helping You Find Your Strength and Serenity.
So we need you to sign a HIPAA Privacy Notice Form and an Authorization for Disclosure of Confidential Information. The latter is used to ask your permission to contact the persons you list on the forms, be they your physicians, insurance company, case manager, or attorney.
Lastly, well need a CONSENT FOR TREATMENT form, and at the end of the first session the therapist will explain all about the consent so you can make an informed choice about your therapy.
These are the forms every therapist in Wisconsin needs in order to begin counseling. We will have you fill out copies of these forms in the waiting room or you can print them out and complete them now. Just bring them with you.
CLIENT REGISTRATION FORM
Fill this out as completely as you can. The therapist will go over it with you to help you make it complete.
CLIENT CONSENT TO TREATMENT FORM
Sign the form and well explain the details at the first session.
CLIENT HIPAA PRIVACY NOTICE FORM
Look the form over and sign it. If you have questions, well be happy to go over it with you.
AUTHORIZATION FOR DISCLOSURE OF CONFIDENTIAL INFORMATION
For each person or organization you want us to contact, please fill out a separate form.
HISTORY (select Family version for adults, Child version for youth)
CLIENT CHILD HISTORY
CLIENT FAMILY HISTORY
(Once you have printed the form, click the "Back" button of your web browser to return to this web page.)
Those are the forms we need. Well also need a copy of both sides your insurance card. You can put most of the information from your insurance card in the appropriate lines on the REGISTRATION FORM. You can also copy both sides of your insurance card and fax with the forms, or just bring it all to the first appointment.
If you have Title 19, Medicaid, or Badgercare, we just need the clients social security number, not the Forward Card.
Our secure fax is: (414) 540-2171.
Youve made an important decision to get help.
Our goal is to schedule therapy away and start as soon as possible.
We hope to make this important step in your life go as easy as possible.