Please use these forms to make your experience at Mascoutah Wellness Center more beneficial.

Below are a list of forms that you can click on, fill out, and return to your counselor.  This can assist the counselor in having a more thorough picture of you as a whole. 

Intake Forms

By filling out and submitting the five intake forms below prior to your first visit, you can speed up the intake process and ensure that authorization with your insurance company is complete prior to the first meeting with your counselor.  You can submit these forms via email, mail, or bringing them by the office in a sealed envelope and dropping them in our locked mailbox.  Please make sure all sections are completed and signed to give us permission to make the proper insurance authorizations. A copy of your valid photo ID along with a copy of the front and back of your Insurance Card(s) will be required also. 

Client Information Form

Client Rights and Confidentiality Form

Financial Policy Form

Insurance Information Form

Credit Card Authorization Form

Any information you can provide prior to the first appointment can be helpful and save time at intake.