Rum River Counseling, Inc.
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                                                                      Intake Forms

                                                                      The following intake forms are to be filled out by all new clients before the intake appointment.  If coming in as a couple, each partner fills out his/her own forms.

                                                                      If you are unable to complete your intake forms ahead of time or forget to bring them, you will need to arrive 15-20 minutes early.  Extra forms are available in wall files in the waiting area.

                                                                      Click on a form title below to open a PDF document of that form.  You will need Adobe Reader to view & print these documents.  It's FREE and you can get it
                                                                      here.  



                                                                      Adult Intake Forms
                                                                      Please bring the completed Counseling Policies, Personal History & Adult PHQ Screening forms to your first appointment.

                                                                      ADULT COUNSELING POLICIES
                                                                      File Size: 808 kb
                                                                      File Type: pdf
                                                                      Download File

                                                                      ADULT HISTORY FORM
                                                                      File Size: 449 kb
                                                                      File Type: pdf
                                                                      Download File

                                                                      ADULT PHQ SCREEN
                                                                      File Size: 401 kb
                                                                      File Type: pdf
                                                                      Download File


                                                                      Wellness Assessments
                                                                      UBH/Medica Insurance ONLY
                                                                      For clients with Medica insurance, in addition to the general intake forms, please bring the completed Wellness Assessment to your first appointment.

                                                                      Adult Wellness Assessment
                                                                      File Size: 105 kb
                                                                      File Type: pdf
                                                                      Download File

                                                                      Youth Wellness Assessment
                                                                      File Size: 107 kb
                                                                      File Type: pdf
                                                                      Download File

                                                                      Youth Intake Forms
                                                                      Please bring the completed Counseling Policies, Personal History & Youth SDQ Screening forms to your first appointment.

                                                                      MINOR COUNSELING POLICIES
                                                                      File Size: 934 kb
                                                                      File Type: pdf
                                                                      Download File

                                                                      MINOR HISTORY FORM
                                                                      File Size: 567 kb
                                                                      File Type: pdf
                                                                      Download File

                                                                      Youth SDQ Screens

                                                                      PLEASE note: Ages 11-17 require both a youth & a parent SDQ screen.
                                                                      Ages 3-4 and 4-10, only a parent SDQ screen is required. 

                                                                      11-17 year olds:

                                                                      SDQ 11-17 SELF REPORT
                                                                      File Size: 580 kb
                                                                      File Type: pdf
                                                                      Download File

                                                                      SDQ 11-17 PARENT REPORT
                                                                      File Size: 580 kb
                                                                      File Type: pdf
                                                                      Download File

                                                                      4-10 year olds:

                                                                      SDQ 4-10 PARENT REPORT
                                                                      File Size: 580 kb
                                                                      File Type: pdf
                                                                      Download File

                                                                      3-4 year olds:

                                                                      SDQ 3-4 PARENT REPORT
                                                                      File Size: 580 kb
                                                                      File Type: pdf
                                                                      Download File

                                                                      Electronic SDQ Screens

                                                                      You can also visit the SDQ website via the links below to complete electronic versions and bring the computer generated report to your intake session.

                                                                      Remember:
                                                                      Ages 11-17 require both a youth & a parent SDQ screen. Ages 4-10, only a parent SDQ screen is required. 

                                                                      Website Links:

                                                                      Youth SDQ - 11-17 yr olds

                                                                      Parent SDQ - 4-17 yr olds

                                                                      Teacher SDQ - 4-17 yr olds

                                                                      This site is presented for information only and is not intended to substitute for professional medical advice. Presentation and Design ©2004-2011 Rum River Counseling, Inc. All Rights Reserved.