Mental Health Intake Paperwork – Client Self-Service – GForm Mental Health Intake Paperwork - Client Self Service Step 1 of 4 25% Client DetailsToday's Date* MM slash DD slash YYYY Client Name* First Last Client Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Person Signing Forms is the: Client Parent/Guardian Name of Person Signing Forms*This may be the client, or the parent/guardian First Last eMail of Person Signing Forms* Demographic InformationThis survey is optional. Please select all that apply to you. AgeChoose a selection here0-1011-2021-3031-4546-5555+How do you identify ethnically? African-American Black African Asian-American Asian Native-American Latinx/Hispanic Somali Hmong Caucasian Multiracial/Other (indicate below) Prefer Not to Say Other Race or Ethnicity What services are you currently receiving? Psychotherapy ARMHS - Adult Skills CTSS - Children Skills Rule 25 Assessment Supervised Visitation Parenting Assessment Diagnostic Assessment Roots Substance Use Treatment Gender Female Male Non-Binary Other Prefer Not to Say What county do you live in? Hennepin Ramsey Chisago Isanti Other Sexual Orientation: Heterosexual/Straight Homosexual/Gay Bisexual Other Prefer not to say Are you currently homeless? Yes No Who referred you to us? Self Child Protection Social Worker Mental Health Social Worker Doctor Other What type of insurance do you have?Choose a selection hereState Medicaid/Medical Assistance PlanCommercial/Employer InsuranceMedicareNo Insurance Minnesota CarePartner Mental Health Services AgreementA. PERMISSION FOR TREATMENT I agree to permit employees of Minnesota CarePartner to provide services to me. I understand that Minnesota CarePartner can make no guarantees about the outcome of my treatment, but that I can expect to receive services that are ethical and professional. I understand that Minnesota CarePartner agrees to comply with all privacy laws and respects my right to confidentiality. As a client, I agree to attempt to be honest and to disclose information to assist the MNCP staff in providing appropriate services. 1. I agree to attend scheduled appointments or notify service providers if I need to reschedule an appointment. 2. I agree to participate in treatment planning, that is, developing and implementing a functional assessment and individual treatment plan.Consent for Services* I provide consent to receive services from Minnesota CarePartnerThese services may include, but are not limited to individual and family psychotherapy, individual skills training, diagnostic assessments, family, parenting and community support services, supervised visitation, substance use disorder services, and any other services provided by the agency. COVID-19 Liability Waiver I attest that: I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19. I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non-contagious by state or local public health I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19. I have not traveled internationally within the last 14 I have not traveled to a highly impacted area within the United States of America in the last 14 days. If so, please tell us where you traveled to and your dates of travel. I acknowledge the following: The contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social Minnesota CarePartner, LLC has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. Minnesota CarePartner, LLC cannot guarantee that I will not become infected with the Coronavirus/COVID-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, counseling staff, and other clients and their families. I voluntarily seek services provided by Minnesota CarePartner, LLC and understand that I am increasing my risk to exposure to the Coronavirus/COVID-19. I will comply with all set procedures to reduce the spread while attending my appointment. I hereby release and agree to hold Minnesota CarePartner, LLC harmless from, and waive on behalf of myself any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the counseling practice, or that may otherwise arise in any way in connection with any services received from Minnesota CarePartner, LLC. I understand that this release discharges Minnesota CarePartner, LLC from any liability or claim that I, my heirs, or any personal representatives may have against the practice with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Minnesota CarePartner, LLC. This liability waiver and release extends to the counseling practice together with all therapists and other employees. COVID-19 Liability Waiver* I acknowledge my risks as stated in this waiver and agree to participate in services.CommentsThis field is for validation purposes and should be left unchanged.
