Therapy for individuals, couples, families & groups

Important Forms

*NOTICE: THE PAPERWORK OPTION IS LIMITED TO ELECTRONIC SUBMISSION DUE TO
PROVIDING TELEHEALTH DURING THE COVID 19 STATE OF EMERGENCY.
PLEASE CALL 218-252-6608 OR 218-252-2785 FOR ASSISTANCE.


Paperwork will need to be filled out prior to your first appointment.  Please click on the links below to fill out your paperwork electronically.  If you need technical assistance, please call 218-252-2785.
Note: To download Adobe Acrobat Reader for free, click here.

Referral Forms
Mental Health
CTSS
Chemical Health

 

Consent Form

Informed Consent Form

Telehealth Permission Form
(REQUIRED FOR ALL CLIENTS DUE TO COVID19 CRISIS)
Please fill out the following form prior to your first Telehealth appointment:

Telehealth Consent Form

 

Mental Health & Chemical Health Intake Form
Please fill out one of the following prior to your 1st appointment:

Children Intake (Ages 0-4)

Child Intake (Ages 4 to 10)

Child Intake (Ages 11-17)

Adult Intake (Ages 18 and up)

 

For Coordination of Care:
(with outside providers, friends, family members, etc.)
Release of Information (FULL Permission)
Release of Information (Customized Permission)

 

Prime West Health Care Directive
(NOT Required):
Information & Application