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 are a third party making a referral to FACTS, please fill out the following form and fax it to us at 651-405-0358:
 REFERRAL INTAKE FORM Please review and sign this form and bring it along to your first session.
HIPAA NOTICE OF PRIVACY PRACTICES If you wish to use insurance in paying for therapeutic services, please complete the following:
INSURANCE RELEASE FORM This form allows your therapist to gather information essential to providing thorough and informed clinical care: (please select the appropriate questionnaire)
HISTORY QUESTIONNAIRE CHILD
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:
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.
CONSENT FOR RELEASE OF PRIVATE HEALTH INFORMATION If you wish to utilize e-mail as a form of communication, please complete and sign the following:
CONSENT FOR EMAIL COMMUNICATION
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 (952) 936-2800.
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