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For Clients & Families: Forms

General Catalpa Documents:

Release of Information/ Authorization for the Disclosure of Health Information   (ROI)  To request copies of medical records or to permit another person to participate in your child’s care, please complete and return. 

Mental Health Treatment Plan   Electronically sign this document when instructed to by your provider. 

Behavioral Health Form For Psychological/Neuropsychological Testing

Form to update your insurance information

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Intake Documents: 

Review:

Sign:  If your child is 14 and older, they will need to sign the paperwork with you.

  • Informed Consent For Treatment By signing this document you are allowing Catalpa Health to provide treatment for your child.
  • Notice of Privacy Practices By signing this document you acknowledge that Catalpa Health has offered you a copy of the privacy practices (above) and that Catalpa follows HIPAA laws and will protect your healthcare information. 
  • Financial Agreement By signing this document you allow Catalpa Health to bill your insurance company for services rendered, and that you are financially responsible for any balance not covered by your insurance benefits. 
  • Client and Family History Form

 The paperwork can only be signed by a biological or adoptive parent. If the child is being cared for by anyone by a biological or adoptive parent, please call us. We know that step-parents, grandparents, foster parents and other family members play an important role in a child’s life, however, these individuals are not able to legally consent to mental health services in the state of Wisconsin.