Mental Health Intake Paperwork – Staff Requested – GForm Step 1 of 2 50% Fill out this form in order to send the intake documents to your client or parent/guardian for signature. Once you complete the form and submit it, an email with a link will be sent requesting review and signature.Staff DetailsName of Staff Requesting Signature* First Last eMail of Staff Requesting Signature* Client DetailsToday's Date* MM slash DD slash YYYY Client Name* First Last Client Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Person 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* Minnesota CarePartner Mental Health Services AgreementA. PERMISSION FOR TREATMENT Please indicate below the services the client is expected to receive and for which you are requesting consent.Consent for Services* I 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. NameThis field is for validation purposes and should be left unchanged.
