Patient Forms

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Release of Information

Electronic Releases

Mental Health Release of Information
Substance Use Disorder Release of Information

Printable Releases

Mental Health Release of Information
Substance Use Disorder Release of Information

Patient Behavioral Screening Questionnaires

PHQ9/GAD7 Screening Tool
UBH Wellness Assessment Adult
UBH Wellness Assessment Youth
CAMS Suicide Status Forms
Borderline Symptom List 23 (BSL-23)
SDQ Ages 4-10
SDQ Ages 11-17

Outpatient Psychiatric Medication Management

Adult Intake Paperwork - NEW PATIENT FORMS
Child/Adolescent Intake Paperwork - NEW PATIENT FORMS
Controlled Medication Agreement
Psychiatric Services Consent Agreement
Tele-Psychiatry Consent Form

Psychological Evaluation

Adult Psychological Testing Intake Form
Child Psychological Testing Intake Form

Outpatient Therapy

Adult OP Therapy Intake Packet
Child OP Therapy Intake Packet

Adult Rehabilitative Mental Health Services (ARMHS)

ARMHS Rights & Responsibilities
Community-Based Notice of Privacy Practices

Case Management (Behavioral Health Home - BHH)

DHS BHH Consent Rights & Responsibilities
Case Management Rights & Responsibilities
Crisis Management Plan
Case Management Notice of Eligibility

Children's Therapeutic Services and Supports (CTSS)

Rights and Responsibilities
Children & Family Fee & Policies Agreement
CTSS Treatment Plan Signature Form
CTSS Financial Release & Privacy Rights Notification
Community Based Notice of Privacy Practices

Adult In-Home Therapy

Adult In-Home Therapy Fee and Policy Agreement
UBH Wellness Assessment
Nutrition Screening Questionnaire
WHODAS

Adult Day Treatment (ADT)

ADT Intake Packet

Nutrition Counseling Services

Intake Packet 18+
Intake Packet 13-17
Intake Packet 12 & Under
Adult Health Screening Questionnaire (18+)
Adolescent Health Screening Questionnaire (13-17)
Child Health Screening Questionnaire (12 & Under)

General Forms

Patient Rights Handout
Notice of Privacy Practices
Fee Agreement
Notice of Nondiscrimination

Suboxone® Intake Packet

Suboxone® Intake Packet

Substance Use Disorder Forms

Evaluation/Assessment

SUD TeleHealth Consent Form
SUD Release of Information
SUD Appeal/Privacy Rights Form
MN DHS Options Opioid Treatment

Orientation

SUD TeleHealth Consent Form
SUD Release of Information
SUD Appeal/Privacy Rights Form
SUD Orientation Form
SUD Orientation Information
SUD Adult Treatment Plan Worksheet
SUD Adolescent Treatment Plan Worksheet

Printable PDF Versions

SUD Evaluation/Assessment Forms
SUD Orientation Info & Forms

Family Program Forms

Confidentiality/Expectations
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