Client Information

Parent/Guardian Information

Only needed for clients age 15 and younger

Health Insurance

Consent to Release

* I consent to have my clinic share the information on this form with Wilder Wilder’s Mental Health Services and that they will contact the identified caregiver.
* I consent to have Wilder provide feedback to my clinic about the status of this referral for mental health.
* I understand I may refuse to sign (and can revoke) this referral and consent, except to the extent that action has already been taken in reliance on this consent.
* I understand that my clinic may not condition treatment/services or payment of bills on decision to sign this referral and consent form.
* I understand that when the information specified on this form is sent to Wilder's Mental Health Services, they have agreed not to re re-disclose the information to any third party other than this clinic and to protect the privacy of this information consistent with state and federal privacy laws.
* I agree that a photocopy of this form is as valid as the original.
* I understand that, upon my request, I will receive a copy of this signed form.
* I have read and agree to the terms above above.