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(480) 508-0882

Scottsdale  |  Tempe

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Scottsdale Mental Health and Wellness Institute
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Pre-Registration Form


  • Please complete the following form to notify us about your need for treatment. Appointments are not provided until this form is completed and we are able to create a patient record in our electronic health system. We require copies of your insurance card front and back and a copy of your license to verify your identity. You can upload these images utilizing this form or send them to admissions@smhwi.com. Once these steps are completed an admissions representative will call you to schedule an appointment. When you complete this pre-registration form an email will be sent to you with instructions on how to set up your patient portal and how to complete your intake forms. Thank you!
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  • PLEASE ACKNOWLEDGE (by checking box)

    I understand SMHWI providers do not provide forensic psychiatry or therapy mandated by court order or state professional licensing boards.

  • PLEASE ACKNOWLEDGE (by checking box)

    SMHWI accepts Medicare, although we are not in network with Medicare Advantage or Medicare Replacement plans. Medicare patient services are limited to select providers and scheduling availability may be limited.

  • PLEASE ACKNOWLEDGE (by checking box)

    SMHWI is not in network with any AHCCCS, Mercy Care or Medicaid insurance plans.

  • PLEASE ACKNOWLEDGE (by checking box)

    If your insurance happens to change prior, during or after an appointment at SMHWI, you will be subject to cash pay if we are out of network with the updated insurance plan.

  • *If patient is a minor and parents are separated, we will require custody documentation prior to an appointment*
  • Please select the services you are interested in receiving at our practice.
  • **(Patients using insurance for appointments will have to provide a copy of the front and back of insurance card prior to scheduling)**
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    CONTACT

    Scottsdale

    Tempe

    TEL: (480) 508-0882

    FAX: (480) 508-0891

    EMAIL: admissions@smhwi.com

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