Intake Forms

After calling to discuss your interest in therapy and scheduling a time for an intake session, please download, review and complete the following forms.

You will need Adobe Acrobat Reader to view the information, which is in PDF 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 below to download a free copy.

If you have questions related to any of these forms, please contact FACTS staff by phone at (651) 379-9800.

If you are a third party making a referral to FACTS, please fill out the following form and fax it to us at (651) 405-0358:

pdf Referral Intake Form
doc
Referral Intake Form

Please review and sign this form and bring it along to your first session.

pdfHIPAA Notice of Privacy Practices
doc HIPAA Notice of Privacy Practices

This form allows your therapist to gather information essential to providing thorough and informed clinical care: (please select the appropriate questionnaire)

pdf History Questionnaire Child
doc History Questionnaire Child

pdf History Questionnaire Adult
doc History Questionnaire Adult

History Questionnaire For Couples/Marriage Therapy (Coming Soon)
If you are seeking couples or family therapy, please review and sign the following:

pdf Couple & Family Confidentiality Agreement
doc Couple & Family Confidentiality Agreement

The following form authorizes your therapist to confer with others concerning your care. This may include physicians, other therapists, schools, clergy, community corrections or social service departments.

pdfConsent for Release of Private Health Information
doc Consent for Release of Private Health Information

If you wish to utilize e-mail and/or text as a form of communication, please complete and sign the following:

pdf Consent for E-mail Communication
doc Consent for E-mail Communication

School Link Mental Health, please complete and sign the following:

pdf School Link Mental Health -- Referral Intake
doc School Link Mental Health -- Referral Intake

Due to the insecure nature of electronic communications, however, please be advised that the privacy of your health information cannot be fully ensured when transmitted by e-mail.

If you have questions related to any of these forms, please contact FACTS staff by phone at (651) 379-9800.