Intake Forms

Minnesota Mental Health Matters

Many of you will be filling out one of the Client Intake Form packets. This is an online PDF format that allows you to fill it out. There are multiple forms in each packet, which means that every page that requires a name / date, etc is there because it is its own form and may be used individually.

Please note that there are over 40 required fields in order to complete the PDF's form. Forms that are not completed (all required fields) will not be accepted. This is your responsibility.

All information submitted on these PDF forms is HIPAA compliant and secure (no information is ever shared).

Please take the time to fill out the forms correctly and have a photo of your insurance card (front and back) ready to be uploaded at the end of filling out the packets.

Thank you and we look forward to working with you.

Online forms to fill out directly

After our initial conversation and your interest in therapy / scheduling time for an intake session, it is necessary to complete one of the Auto fill PDF's Intake Packets. Please click on the appropriate one you were assigned by your prescriber below:

Client Intake packets

For established patients, please complete upon request:

Individual intake forms (click and print out to manually fill out):

In the case you are using the PDF forms here on the right, you will need Adobe Acrobat Reader or Microsoft Word to view the information, in PDF or Word format. If you have Acrobat Reader, you can immediately view the information. If you don’t have Acrobat Reader, you can click on the icon here to download a free copy.

Need Adobe acrobat?

Authorization for telehealth medicine

Client Information intake Form

HIPAA notice of Privacy Practices

Permission Status / Insurance Release and Responsibility Form

Child Symptoms Checklist

Adult Symptoms Checklist

Consent for Release of Private Health Information

Consent for Email communication (Electronic Communication)

Medication Checklist (Past and Present)

(available for online fill < )

Here are the form packets (non auto-fill) for those who like to print them out / fill out completely and bring with you to your appointment.

Child Intake Form Packet Age 4-10

Adult Intake Form Packet

Child Intake Form Packet Age 11-17

[fa icon="plus-square"] New clients need the following:

Client Information Form intake form

HIPPA notice of Privacy Practices

Permission Status / Insurance Release and Responsibility form

[fa icon="plus-square"] Child Adolescent forms

[fa icon="plus-square"] WHODAS & GAD7 + PHQ9 (Adults Only)

Please print one of the following:

and one of these too:

GAD7 and PHQ9 forms

Intake Forms for patients

Minnesota Mental Health Matters

Online forms to fill out directly

Client Intake packets

Individual intake forms (click and print out to manually fill out):

Mental Health help for improving your life

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Medical Disclaimer: All services are provided at our clinic, and not by email. If you need medical assistance, please call our clinic or visit us in person.

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