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
| |||||||||||||||||||||||||
| ADULT COUNSELING POLICIES |
| ADULT HISTORY FORM |
| ADULT PHQ SCREEN |
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 |
| Youth Wellness Assessment |
Youth Intake Forms
Please bring the completed Counseling Policies, Personal History & Youth SDQ Screening forms to your first appointment.
| MINOR COUNSELING POLICIES |
| MINOR HISTORY FORM |
Youth SDQ Screens
Ages 3-4 and 4-10, only a parent SDQ screen is required.
11-17 year olds:
|
| ||||
4-10 year olds:
| SDQ 4-10 PARENT REPORT |
3-4 year olds:
| SDQ 3-4 PARENT REPORT |
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