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.
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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
Referral Intake Form
Please review and sign this form and bring it along to your first session.
HIPAA Notice of Privacy Practices HIPAA Notice of Privacy Practices
If you wish to use insurance in paying for therapeutic services, please complete the following:
Insurance Release Form 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 Child
History Questionnaire Adult 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 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 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:
Consent for E-mail Communication Consent for E-mail 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 (651) 379-9800.
