Intake Paperwork – WPForm Please enable JavaScript in your browser to complete this form.Client Information – Step 1 of 3Client InformationToday's Date is *Client Name *FirstMiddleLastClient Date of Birth *Name of Person Signing Forms *FirstLastThis can be the client’s name or the parent/guardian.Person signing forms is: *ClientParent/GuardianEmail of Person Signing Forms *Next: Demographic SurveyDemographic InformationThis survey is optional. Please select all that apply to you.Age0-1011-2021-3031-4546-5555+How do you identify ethnically?African-AmericanAsian-AmericanNative-AmericanLatino/HispanicSomaliHmongCaucasianMultiracial/OtherPrefer Not to SayOther Race/EthnicityWhat services are you currently receiving?PsychotherapyARMHS – Adult SkillsCTSS – Children SkillsRule 25 AssessmentSupervised VisitationParenting AssessmentDiagnostic AssessmentRoots Substance Use TreatmentGenderFemaleMaleNon-BinaryOtherPrefer Not to SayOther GenderWhat County do you live in?HennepinRamseyChisagoIsantiOtherOther CountySexual OrientationHeterosexual/StraightHomosexual/GayBisexualOtherPrefer not to sayOther Sexual OrientationMilitary StatusVeteranActive Duty MilitaryNational Guard/ReservesNot in the militaryAre you currently homeless?YesNoWho referred you to us?SelfChild Protection Social WorkerMental Health Social WorkerDoctorWhat type of insurance do you have?State Medical Assistance PlanCommercial/Employer InsuranceNext: Mental Health Services AgreementMinnesota 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.Under the above-mentioned conditions: *I wish to receive:Desired Services *ARMHSCTSSDiagnostic AssessmentsRule 25 AssessmentSupervised VisitationsOtherOther desired servicesDo Not Wish to ReceiveI do not wish to receive:Undesired ServicesARMHSCTSSAssessmentSupervised VisitationsOtherOther undesired services:PhoneSubmit
