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 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.
Information Form
Insurance Information Form
Checklists and History
These forms will give you a list of symptoms and/or characteristics to review that will allow the counselor to see what you are experiencing, assist in making a proper diagnosis, and/or assist in determining the services of your treatment.
Checklist of Concerns
Child Checklist of Charachteristics
Child Development History Record
Any information you can provide prior to the first appointment can be helpful and save time at intake.