Forms

New Client Intake Packets

To be completed only if you have already been assigned a clinician

Wise Mind Studio Intake Packet

Adult Intake Packet – Other Payor

DBT Intake Packet – Other Payor

EASE Intake Packet – Other Payor

Admissions Testing Registration Form

DBT Applications

(For use only if your clinician has instructed you to fill out something separate from the packets listed above)

Credit Card Authorization Form – Therapy

Credit Card Authorization Form – Assessment/ Consultation

Credit Card Authorization Forms – Designating Another Payor

Group (Non-DBT) Telehealth Form

DBT Skills Group Telehealth Form

Pre-DBT STAT Outside Provider Agreement/Crisis Plan

Other

If you would like a copy of the Good Faith Estimate (GFE) which provides the maximum costs in a calendar year for various types of services we provide, please click this link. This calculation of fees is offered in compliance with the Department of Health and Human Services ‘No Surprises Act.’

WKG HIPAA Notice Form

Good Faith Estimate

Patient Forms

New Client Intake Packets

Wise Mind Studio Intake Packet

Adult Intake Packet

DBT Intake Packet

EASE Intake Packet

Adult Intake Packet – Other Payor

DBT Intake Packet – Other Payor

EASE Intake Packet – Other Payor

Child Intake Packet

Testing Intake Packet

Admissions Testing Registration Form

DBT Applications

DBT Application

EASE Application

Wise Mind Studio

Forms

Wise Mind Studio Agreement

Release of Information Form

Credit Card Authorization Form – Therapy

Credit Card Authorization Form – Assessment/ Consultation

Credit Card Authorization Forms – Designating Another Payor

Debit Card Authorization Form

Consent for Services

Telehealth Informed Consent

Group (Non-DBT) Telehealth Form

DBT Skills Group Telehealth Form

Pre DBT STAT Client Agreement

Pre-DBT STAT Outside Provider Agreement/Crisis Plan

DBT Client Agreement

Other

WKG HIPAA Notice Form

Good Faith Estimate

Book a Consultation