Forms
Forms

Download Forms

If you are not able to fill the intake paperwork out via our online portal (call us for more information about the online portal), please download the applicable forms using the links below. Fax completed forms to 855-847-9876 or bring them with you to your appointment. Additional paperwork may be requested, depending on your insurance company and provider.

For children, all appropriate pages must be signed by the legal guardian. A consent to treat must be signed by ALL legal guardians. For children ages 11 and up, the child should fill out the Strengths and Difficulties Questionnaire marked S; parents should fill out the Strengths and Difficulties Questionnaire marked P.

For vulnerable adults, all appropriate pages must be signed by the legal guardian. Eunoia will need proof of guardianship by the time of the appointment.

ADULT PATIENT FORMS

PDF download includes the following forms: registration form, financial policy and privacy policy and acknowledgement page, authorization for release of information and 5 intake screeners.
Adult Intake Packet

CHILD PATIENT FORMS

PDF download includes the following forms: registration form, consent to treat a minor form, financial policy and privacy policy and acknowledgement page, authorization for release of information and 2 intake screeners (for children ages 4-10) or 3 intake screeners (for children ages 11-17).
Child Ages 4-10 Packet Child Ages 11-17 Packet

VULNERABLE ADULT PATIENT FORMS

PDF download includes the following forms: registration form, consent to treat a vulnerable adult form, financial policy and privacy policy and acknowledgement page, authorization for release of information and 5 intake screeners.
Vulnerable Adult Intake Packet

REFERRAL FORM (ALL OFFICES)

PDF download includes a Referral Form for all offices. Please mail completed form to Eunoia Family Resource Center, 1420 N. State Street, Fairmont, MN 56031; or fax to 855-847-9876.
Referral Form