Intake Forms

Please feel free to print off and complete the following forms for the appropriate program or service. 

Adolescent Treatment and Child Treatment Programs

• ATP Cover Sheet
• Authorized Consent to Treatment and Payment and Privacy Practice
• Community Service Record
• Consent for Release of Information
• Health History
• Intake Interview
• Internet Computer Use Permission Form
• MCCCA Consent SDRS Form
• Medical Insurance Form
• Medical, Psychiatric, Dental and Optical Permit
• Missing Person Report
• Multiple Consent Forms Combined
• Nonspecific Release attachment to Consent for Release of Information TSA
• Prescription Information
• Previous Placement Services
• Referring Worker Checklist
• Shelter Intake Interview
• Substitute Care and Respite Care Notice

In-Home Family Based Services and Outpatient Services

• Authorized Consent to Treatment and Payment and Privacy Practice
• Client Info and Office Policy Statement
• Client Information Questionnaire
• Child Medical/Social History Questionnaire
• Client Rights and Responsibilities and Mission Statement
• Consent for Release of Information
• Notice of Privacy Practice (Form 23000)
• Referral Form
• Referral Procedures

        Service Delivery Evaluation

School Based Mental Health Services

         School Based Mental Health Service Referral Form

Privacy Practice

For more information or to make a referral, call:

320-629-7600 or  651-224-4114