MCPST Forms

Following are MCPST’s New Client Intake Forms and other forms for our clients.  Wisconsin Statutes require all clients to complete several forms prior to their first session.  Please download, print and complete the forms per your therapist’s instructions and bring them with you to your first appointment.

If you are not able to print any of the forms, please contact your therapist who will make them available for completion in our office 30 minutes before your intake appointment.  Or will arrange for you to pick up the forms at our office to complete at home and bring with you to  your first session.  Please talk to your therapist if other arrangements need to be made.

If you are using health insurance, please bring your health insurance card and a photo ID to your first appointment.  We will need to make a copy of the photo ID and both sides of your insurance card at the time of your appointment.

If you are the parent or guardian of a minor child, please complete and sign the forms for the child.

If you have any questions, please contact your therapist or our Office Assistant Denise at (608) 237-8000 x3.

Please download, print, read and complete the following forms per your therapist’s instructions and bring them with you to your appointment.  Your therapist will review the forms with you in the session and answer any questions you have about them.

Eight Forms For New Clients Who Are Using Health Insurance:

  1. MCPST Billing-Insurance Information Form gives you information about MCPST clinic policies and procedures; fees for intake and ongoing psychotherapy sessions; private pay fee agreement; assignment of benefits for insurance; asks about client and insurance information, and explains information we may release to your insurance company with your permission per their requirement for coverage of services. (2 pages) Read, complete and sign all relevant sections of both pages.
  2. Credit Card Payment Authorization Form is a courtesy we offer our clients to have their copays and/or session fees charged directly to their credit card.  This form is optional and kept confidential and private. (1 page)
  3. MCPST Intake Questionnaire asks for information about you, the issues that bring you into the clinic and your treatment goals so that we can best provide services for you. (2 pages) Complete entire form.
  4. MCPST Informed Consent explains informed consent as a client in the clinic. (1 page) Read and sign.
  5. MCPST Health Insurance Portability and Accountability Act (HIPAA) Privacy Practices Form describes legal use and disclosure of health information. (4 pages) Read.
  6. Receipt of HIPAA Privacy Practices acknowledges that you have received and understand the HIPAA form. (1 page) Read and sign.
  7. Client Bill of Rights tells you your rights as a client in the clinic. (1 page) Read.
  8. MCPST Insurance Benefits Worksheet provides information and has questions to ask your insurance company to get accurate information about your mental health benefits. (2 pages) Complete and use as reference when calling insurance company to clarify benefits.

Seven Forms For New Clients Who Are Paying Privately:

  1. MCPST Billing-Insurance Information Form gives you information about MCPST clinic policies and procedures; fees for intake and ongoing psychotherapy sessions; and private pay fee agreement. (2 pages) Read, complete and sign all relevant sections of both pages.
  2. Credit Card Payment Authorization is a courtesy we offer our clients to have their copays and/or session fees charged directly to their credit card.  This form is optional and kept confidential and private. (1 page)
  3. MCPST Intake Questionnaire asks for information about you, the issues that bring you into the clinic and your treatment goals so that we can best provide services for you. (2 pages) Complete entire form.
  4. MCPST Informed Consent explains informed consent as a client in the clinic. (1 page) Read and sign.
  5. MCPST Health Insurance Portability and Accountability Act (HIPAA) Privacy Practices Form describes legal use and disclosure of health information. (4 pages) Read.
  6. Receipt of HIPAA Privacy Practices acknowledges that you have received and understand the HIPAA form. (1 page) Read and sign.
  7. Client Bill of Rights tells you your rights as a client in the clinic. (1 page) Read.

Form Giving Permission for Client Information To Be  Released:

MCPST Authorization for Release of Information authorizes release of information to and from another person, for example psychiatrist or former therapist, for your benefit, i.e. in order to coordinate services for you. (1 page) Read and complete name, contact information and dates of contact for person with whom your therapist will share information. Your therapist will complete the rest of the form with you in their office.

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Midwest Center for Psychotherapy & Sex Therapy · 6300 University Avenue, Suite 125 · Middleton, WI 53562 · (P) 608-237-8000 · (F) 608-237-8005