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Patient registration formNEW CLIENT PACKET

There are two ways to start service with A WiserMind--completing an Intake Packet, or by submitting a referral form.   Please select the option that fits your needs and we'll walk you through the appropriate process.

Intake Packet | Referral Form

      Supporting your Brain Health – Getting Started  Thank you for your interest in A Wiser Mind’s services. Our therapy is designed to offer a wiser way of providing cognitive therapy and emotional care that focuses on you as an individual with a unique background and set of skills. Your therapist will create a personalized plan specific to your needs and, where possible, meet with you in your home. We take care of checking your insurance benefits, obtaining diagnoses and answering any family and caregiver questions. We will not begin delivering any services before you ask us to start and you will not be charged for working with your insurance company or your doctor to verify benefits or obtain diagnoses.

Beginning the Process 

Our Brain Activation Therapy and Emotional Wellness Therapies are types of mental health services.  Because we are a health organization, federal, state and insurance regulations require that we collect some information and share some information with you. We promise to keep the paperwork to a minimum. The Intake Packet consists of the following 3 forms, provided prior to the start of services. They are designed to help you understand your rights, responsibilities, and expectations are as well as those of A Wiser Mind before, during, and after treatment.
  1. Simple Service Agreement(link to pdf)-This defines the expectations between A Wiser Mind and you, explaining the responsibilities of both parties for the duration of your treatment.
  2. Rights & Disclosures - Choose the form for the state in which you live, Colorado (link to pdf)-  or Arizona (link to pdf)-  This form explains the training and licensure of our clinicians and offers details about the types of therapy provided, confidentiality requirements and how/when information can be shared.
  3. Release of Information (link to pdf)-This form explains your privacy rights and specifically what information can be shared and with whom. Your privacy is very important to us. Under the federal law known as the Healthcare Insurance Portability and Accountability Act (HIPAA), you can ask us to share or withhold specific details of your care and you can change your selections whenever you wish.
Once we receive your inquiry or referral, we will:
  • get permission to speak with your medical provider to coordinate our services with your doctor’s care plan
  • explore your insurance benefits and gather identification numbers, Plan ID or group numbers (if any), phone number and mailing address
  • explain your privacy rights, personal care and health records we will create on your behalf
  • collect your completed Intake Packet of forms
  • gather health information and diagnosis from your doctor (when necessary)
  • obtain your physical address, date of birth and contact information for the responsible party (medical and financial power of attorney) if different from the client.

Download your Intake Packet and get started on your personalized therapy plan to support your brain health.Please contact us or call 888-982-9899 for more information. We’re happy to answer all your questions.