School Based Mental Health Intake

Start the Process Today

Thank you for your interest in Wellpoint Care Network’s School Based Mental Health Program. Our services are based out of our Outpatient Clinic, located at 8901 W. Capitol Dr. in Milwaukee, Wisconsin.

Check below to see if your child’s attends one of our current locations.

Intake Forms

Our therapists look forward to working with you and your child as you embark on your healthcare journey. To help speed up the intake process, please complete the fillable PDF forms below. If you have any questions, please do not hesitate to call us at 414-465-5770 or Contact Us.

Speed up the intake process by completing the following form for the child seeking treatment and submit the information directly from within the form prior to your first visit.

DOWNLOAD SCHOOL BASED MENTAL HEALTH INTAKE FORM [PDF]

The following forms provide you with helpful information about our treatment policies, as well as our strict adherence to HIPAA Privacy Practices. We appreciate your patience and careful review of these documents prior to signing the above forms.

DOWNLOAD NEW CLIENT INFORMATION FOR CHILDREN AND TEENS [PDF]

Frequently Used Forms

Below, we’ve collected the most frequently-used forms and other healthcare-related documents for your ease of access. If you are looking for something specific not listed here, please call us at 414-465-5770 or Contact Us.

Wellpoint Care Network is committed to maintaining the privacy of your Protected Health Information. This Notice explains how that information may be used and disclosed to others, effective as of June 1, 2018.
DOWNLOAD FULL NOTICE [PDF]

All individuals who have received services at Wellpoint Care Network have the right to access their medical records in accordance with DHS 51.30. To request a copy of your medical records, complete the form below and submit with a proof of identification via fax (414-260-8980), email or in-person. Requests for clients age 14-17 must contain client and parent signatures.

DOWNLOAD RECORDS REQUEST FORM [PDF]

If cost of services is preventing behavioral health treatment, Wellpoint Care Network offers Financial Assistance based on the Federal Poverty Guidelines and a sliding fee schedule.

DOWNLOAD FINANCIAL ASSISTANCE POLICY [PDF]
DOWNLOAD FINANCIAL ASSISTANCE APPLICATION [PDF]

 

Under the law, individuals who are not using health coverage to pay for services have the right to receive a “Good Faith Estimate” explaining how much services will cost before they are provided.

DOWNLOAD GOOD FAITH ESTIMATE POLICY EXPLANATION [PDF]
DOWNLOAD SELF PAY WAIVER AND GOOD FAITH ESTIMATE [PDF]

When you get emergency care or are treated by an out-of-network provider at an in-network care facility, you should not be charged more than your plan’s copayments, coinsurance and/or deductible.
DOWNLOAD NO SURPRISE BILLING POLICY [PDF]

Read a full list of Our Policies.

Current Schools Served

Wellpoint Care Network Therapists are available for school based services in the following locations, sorted by district. If you do not see your child’s school in the list below, please call our office at (414) 465-5770 or Contact Us to inquire about services at our Outpatient Clinic.

St. Joseph Academy – SBMH

Central City Cyberschool

Pilgrim Park Middle School
Wisconsin Hills Middle School
Burleigh Elementary
Swanson Elementary
Tonawanda Elementary
Turning Point

Erin School

Germantown High School
Kennedy Middle School

Friess Lake Elementary
Richfield Middle School

Ben Franklin Elementary
Riverside Elementary
Valley View Elementary
Shady Lane Elementary

Messmer-Saint Mary

Pewaukee High School
Asa Clark Middle School
Horizon Elementary
Pewaukee Lake Elementary

Southside Community Prep
North Transformation Prep

Seeds of Health Elementary
Tenor High School-Journal
Tenor High School-Cathedral Square
Veritas High School

South Milwaukee High School
South Milwaukee Middle School
Rawson Elementary
EW Luther Elementary
Blakewood Elementary
Lakeview Elementary

Watertown High School

Dotke Project Based Learning High School
Walker Elementary
Mitchell Elementary
Pershing Elementary
Irving Elementary
Hoover Elementary
Jefferson Elementary
Franklin Elementary
Horace Mann Elementary
Wilson Elementary
West Milwauke Intermediate
Frank Lloyd Write Intermediate
Central High School
Nathan Hale High School

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