WISE MIND: Policies / Forms

If you are interested in an initial screening, contact us at 715-384-0080. Please note that due to our caseloads, we are experiencing delays in screening and appointing new patients. We will generally start with asking the some information about referral source, services you’re interested in, prior treatment, insurance, etc. Following the phone screening, we can send you a forms packet or you can print them from here.  Please make sure the phone screening is completed prior to printing these forms. The Adult History Forms and Policies Packet is for adults, 18 and over. The Child/Teen History Forms and Policies Packet is for 17 and under. The full packet includes our Notice of Privacy Practices, Billing Authorization, and Patient Rights information. Please sign where indicated and fax (715-384-0090) or mail back to us. You may also leave the completed forms in our locked mailbox in the front of our office. We request that you not “stop in” to drop off forms, as we are generally meeting with other patients during our office hours.

Adult Intake History and Consent Forms Packet

Child/Teen History and Consent Forms Packet

If you are referred by a physician or other care provider you may wish to sign a release of information. Our clinicians can help you complete the release to insure that you are aware of what information is to be shared, and what the purpose of sharing the information is.

Release of Information

Privacy and Confidentiality: Your privacy is very important to us. We strongly believe that information that you share with us is both private and confidential. We believe that you should be the person who decides what information is shared. Sharing information with other health care providers, such as a psychiatrist or primary care provider, can be very helpful, but we believe that you should be involved in the decision to share that information.

Additionally, our offices allow parking behind the building and we ask that all patients respect each other, by keeping private anyone else who might be in the waiting room. Your information is confidential and legally protected. This information may not be released to anyone without your written consent. Your therapist will work with you to decide what information would be helpful to share with other health care, social service, education providers, or family members and friends. If you are billing insurance for services, you will sign a release of information/billing authorization for your insurance company. Typically the information shared with insurance companies and other medical providers includes diagnosis, symptoms, treatment plan, progress, prognosis, goals/outcome measures.

There are legal exceptions to confidentiality, including danger/threat to self, danger/threat to others, child abuse, elderly abuse, and information directly to provide care needed in an emergency treatment situation. Please talk to our clinical staff about any questions about confidentiality.

Patients/Clients/Consumers: We use the word patients to describe the people that we see. The primary reason is that we believe that mental health care should have the same importance as any physical health care. We never hear of someone being called a “heart health consumer” or “an orthopedic client.” As in other medical care, patients are actively involved in the determination of their care. We have been entrusted with providing this care, and we believe that the term patient comes closest to clarifying the roles and responsibilities that we take seriously.