Outpatient Mental Health Clinic Intake

Start the Process Today

As the need for mental health care has steadily increased in recent years, Wellpoint Care Network’s outpatient clinic has stood at the ready. We provide therapeutic support for a variety of mental health needs and accept a variety of insurance options, including Medicaid.

Wellpoint Care Network’s Outpatient Clinic is located at 8901 W. Capitol Dr. in Milwaukee, Wisconsin and is open Monday through Friday 8 a.m. to 7 p.m. If you have any questions, please do not hesitate to call us at 414-465-5770 or Contact Us.

New Patient Paperwork

Our clinicians look forward to working with you as you embark on your healthcare journey. To help speed up the intake process, you can complete your New Patient Paperwork online prior to your first visit.

Anyone under the age of 18 will need a parent or guardian to complete and sign on their behalf.

The New Patient Disclosure Forms available below will provide you with helpful information about our Outpatient Clinic policies, as well as our strict adherence to HIPAA Privacy Practices. Please review thoroughly prior to signing your online intake form.

COMPLETE ONLINE INTAKE FORMS
READ NEW PATIENT DISCLOSURE FORM (UNDER 18)
READ NEW PATIENT DISCLOSURE FORM (18+)

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 February 24, 2025.
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.

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