Patients seen in Behavioral Health will be presented with the paperwork below when attending their initial appointment and at set intervals through their care. This paperwork satisfies our legal and regulatory requirements.
Consent for Treatment
The consent for treatment allows us to treat the patient at Gundersen Lutheran. Please initial the small line on the top portion of the page and sign your complete name at the bottom where indicated. Get the Consent for Treatment form
Screening forms assist your provider in knowing where to begin in therapy with you. Please fill it out as completely as you can. If there is a question that does not apply, please write N/A. If there is a section you do not feel comfortable answering, you can leave that blank and the provider you are seeing will talk with you about it.
The Adult screening form is to be completed for patients age 18 or older. Get the Adult Screening Form.
The Child & Adolescent screening form is to be completed for patients age 17 or younger. Get the Child & Adolescent Screening Form.
Verbal Authorization Form
This form allows us to call you regarding your appointments and lets us know if is okay to leave a message for you. You also can list up to five individuals that you wish us to be able to verbally communicate with. You have the right to limit the information as you wish. This form is valid for two years. If the patient is a child who is 12 years of age or older, the child must also sign this form due to the legal requirements related to the treatment of alcohol and/or drug abuse. Without the child’s signature, the form is invalid. If you have questions about this, please contact the Health Information Manager at Gundersen Lutheran at (608) 775-2287. Get the Verbal Authorization form
Release of Information for Primary Care Doctor
The Release of Information form allows us to release information to your primary care doctor. This form allows the Behavioral Health provider to coordinate care you’re receiving with your primary physician. The form is good for one year from the date of signature. Get the Release of Information form
Release of Information for Insurance
The Release of Information form allows us to release information to your insurance company or companies. Oftentimes, Behavioral Health care requires prior authorization by your insurance company. We need this form in order to be able to release any clinical information to your insurance company. The form is good for one year from the date of signature. Get the Release of Information form
At an appointment these forms are given to the patient/guardian to review. These forms explain Rights and Responsibilities, Description of Services, Grievance Procedure, Emergency Services, Fee Schedule and Release of Information in Limited Circumstances.
Patient Rights and Responsibilities
Your rights and responsibilities as a patient at Gundersen Lutheran can be found by clicking here.
Your rights and responsibilities as a patient in Behavioral Health are available here
Description of Services
This is a description of the services available in Behavioral Health at Gundersen Lutheran. View our description of services
We ask if you have a concern with your provider, you discuss it with your provider first. If that does not result in positive resolution, the grievance procedure is here for you to follow. View the grieveance procedure
The emergency service listing explains what to do in case of a Behavioral Health emergency. View the emergency service listing
The fee schedule shows the current charge schedule for Behavioral Health services. View the fee schedule.
Release of Information for Limited Circumstances
This form discusses your confidential record at Gundersen Lutheran Behavioral Health. A separate record is kept for your Behavioral Health care. However, there are certain items that are felt important to be shared throughout the medical facility. They are: the fact that you are a patient in Behavioral Health, any medications that may be prescribed by a Behavioral Health Psychiatrist, any allergies, and any lab tests. Also, if you're seen as a patient at Gundersen Lutheran’s Trauma and Emergency Center, those physicians also have access to your Behavioral Health care record for best patient care. Get the Release of Information for Limited Circumstances form
Other Behavioral Health Forms
Consent Relating to the Treatment of a Minor Patient
This form gives you the right to assign another person to consent to treatment of your minor child. You could give this consent to the minor child him/herself or to someone else of your choice. This form is good for two years from the date of your signature. Get the Consent Relating to the Treatment of a Minor Patient form
Revocation of Authorization
If you sign a release on information form and subsequently something changes that you wish to revoke that release, please complete this form and send it to Behavioral Health. Upon receipt, we will terminate that initial release of information form. Get the Revocation of Authorization form