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New clients need to come to Siouxland Mental Health Center at 625 Court Street to fill out new patient paperwork between the hours of 8:00 to 3:30 Monday through Friday. If you have insurance, please call them to verify that it has mental health benefits and that we are covered under your plan. Please bring your insurance card with you at the time you come in to fill out the paperwork. We do accept Title 19 of Iowa only. If you do not have insurance and/or your insurance does not have mental health benefits and are a Woodbury County resident, then you are able to fill out forms for financial assistance through the county. Items that need to be brought with you at the time include:
1. HOUSEHOLD INCOME VERIFICATION REQUIREMENTS:
For applicants 18 years of age and over: include income of applicant, applicant’s spouse or domestic partner, and any children, stepchildren, or wards over the age of 14 that reside with applicant.
For applicants under the age of 18: Include income of applicant (if over 14), applicant’s parents (or parent and domestic partner), stepparents, or guardians who reside with applicant.
- Copies of payrolls stubs for past 60 days from all employers. If a payroll stub reflects year-to-date earnings, only the most recent payroll stubs will be required.
- If applicant or spouse/domestic partner is self employed, provide a copy of most recent Federal tax return completed.
- If applicable, a copy of Supplemental Security (SSI) or Social Security Disability (SSD) determination, pension payment, and child support amount, etc.
- If an applicant indicates that no one in the household has any income, written documentation is required from all applicable adult household members stating as such and evidence of outside assistance such as food stamps, financial help from relatives, etc., must be provided.
2. RESOURCE VERIFICATION REQUIREMENTS (Applicant and other applicable household members).
- A copy of all checking account statements for the past 2 months.
- A copy of all savings account statements for past 2 months.
- A copy of a statement from all retirement accounts such as IRAs, 401 (k), pension plans, annuities, certificates of deposit, stocks, bonds or trust fund accounts dated no earlier than the previous tax year.
3. PROOF OF RESIDENCE REQUIREMENT
- A copy of the applicant’s driver’s license or picture I.D. that shows current address, OR
- A copy of a recent bill or piece of mail with a legible postmark delivered by the U.S. Post Office to the client at their current address.
4. PAYEE INFORMATION PROVIDED
- If all financial information must come from an applicant’s payee, do not put “contact payee” without signing a release of information form that includes the payee’s name and agency (if applicable).
- Provide the phone number and mailing address of the payee.
Please allow time to fill out all paperwork and time to go over the paperwork with an intake person so that an appointment can be scheduled. You will be seen on a first come, first serve basis. If the patient is an adult, the patient must be present to go over the paperwork. If the patient is a child, then legal guardian must be present to go over paperwork. If child has been adopted or is in a custody situation, please bring all legal paperwork stating this with you for us to make copies for their chart. In order to provide continuity of care, we will need to receive records for all previous treatment, so please bring names and addresses of previous providers such as psychiatrists, therapists, substance abuse services, and mental health hospitals due to releases needing to be signed.
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