Family Based Therapy Associates :: Offices in Coon Rapids, Chisago City and Cambridge, Minnesota






Intake Forms

The following intake forms may be filled out before your intake appointment.  If you are coming in as a couple, note that each of you are to fill out your own set of forms.  ADHD Clinic intake forms can be found on the ADHD Clinic page of this website.

If you are unable to complete the intake forms ahead of time or forget to bring them, please arrive 15-20 minutes early.  Forms will be available to you when you arrive at the clinic.

Click on a form title to open a Microsoft Word document of that form.  You may complete the form by word processing or by handwriting in the requested information.  Please print and bring these to your first session.

Please note:  All forms are in Microsoft Word 97-2003 format.  If you do not have access to Microsoft Word, you can download a free version of Open Office by clicking HERE.


Client Intake Forms
Please bring the Intake Paperwork, Consent for Treatment, and Release for Primary Care Physician forms to your first appointment.

Intake Paperwork
Client/Insured Information
Download File

Intake Paperwork
Consent for Treatment
Download File

Psychological Services, Policies and Procedures
Download File

HIPAA Privacy Practices
Download File

Release for Primary Care Physician
   Word Processing Version
   Download File

   Handwritten Version
   Download File

 

Adult Intake Forms
Please bring the completed Diagnostic Assessment and Adult PHQ Screening forms to your first appointment.

Child/Adolescent Intake Forms
Please bring the completed Diagnostic Assessment & Youth PSC Screening forms to your first appointment.

Adult Diagnostic Assessment
Download File

PHQ-9
Download File

DAST-10
Download File

MAST
Download File

For Clients with
UBH/Medica Insurance ONLY
For clients insured by Medica (Commercial or MN Health Care Plans), you are asked to complete this Wellness Assessment.

   Adult Wellness Assessment
   (18 and older)
   Download File

Child/Adolescent Diagnostic Assessment
(Parent Version)
Download File

Pediatric Screening Checklist (PSC)
PLEASE note: Ages 11-17 require both a youth and a parent PSC screen.

   PSC Self Report
   Download File

   PSC Parent Report
   Download File

For Clients with
UBH/Medica Insurance ONLY
For clients insured by Medica (Commercial or MN Health Care Plans), you are asked to complete this Wellness Assessment.

   Youth Wellness Assessment
   (Under 18)
   Download File



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