Rum River Counseling, Inc.

 

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.

COUNSELING POLICIES
File Size: 813 kb
File Type: pdf
Download File

HISTORY FORM
File Size: 1322 kb
File Type: pdf
Download File

ADULT PHQ SCREEN
File Size: 33 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.

COUNSELING POLICIES
File Size: 971 kb
File Type: pdf
Download File

HISTORY FORM
File Size: 1322 kb
File Type: pdf
Download File

Youth SDQ Screens

Please note that for ages 3-4 and 4-10, only a parent SDQ screen is required.  Ages 11-17 require both a youth & a parent SDQ screen.

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

Website Links:

Youth SDQ

Parent SDQ

Teacher SDQ