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.
Adult Intake Forms
Please bring the completed Counseling Policies, Personal History & Adult PHQ Screening forms to your first appointment.
Youth Intake Forms
Please bring the completed Counseling Policies, Personal History & Youth SDQ Screening forms to your first appointment.
IMPORTANT: If there is a separation, divorce or custody agreement, the Important Signatures page of the Minor Counseling Policies must be completed & signed by the minor’s parents or guardians and faxed to 612-235-6447 or scanned and emailed to firstname.lastname@example.org. Our office must receive the Important Signatures page of the Minor Counseling Policies from BOTH parents before scheduling the intake appointment.
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.
Within our private practice model, your therapist is your primary contact, so you will not need to check in with a receptionist upon arrival. Please take a seat in our waiting area and your therapist will greet you for your appointment. Please bring the following REQUIRED items to your intake appointment:
- Completed and Signed Counseling Policies forms
- Completed Personal History form
- Completed PHQ (adults) or SDQ (minors)
- Photo ID (of legal guardian, if client is a minor)
- Insurance card(s) (also bring MA card if you have one)
- Payment for copay or other financial responsibility (cash, check, credit/debit card, or HSA card)