Children Mental Health Intake Form

Children's Mental Health Intake Information
Blue Earth County Human Services

410 S. Fifth Street

PO Box 3526

Mankato, MN 56002-3526
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Completed By:
Referred by/Phone #:
(000) 000-0000Format: (000) 000-0000.
Date Referral Source Contacted:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If referral was made by provider, does the parent(s) know the referral was made.
PERSONAL INFORMATION
Child's Information
Child's Name:
Child's DOB"

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Address:

Street Address

Street Address Line 2

CityState

Zip Code
Child's Phone No.:
(000) 000-0000Format: (000) 000-0000.
Select the Child's Race Catagory:
Asian Subgroup:
Native Hawaiian/Pacific Islander Subgroup:
Please specifiy other race:
Tribe:
Hispanic:
Child's SSN:
Child's School:
Grade:
Parent/Guardian Information
Include Parent 1 Information?
Parent 1 Information
Is Parent 1 a Guardian?
Parent 1 Name:
Parent 1 DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent 1 Address:

Street Address

Street Address Line 2

CityState

Zip Code
Parent 1 Phone No.:
(000) 000-0000Format: (000) 000-0000.
Upload any Custody Papers:

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Include Parent 2 Information?
Parent 2 Information
Is Parent 2 a Guardian?
Parent 2 Name:
Parent 2 DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent 2 Address:

Street Address

Street Address Line 2

CityState

Zip Code
Parent 2 Phone No.:
Format: (000) 000-0000.
Include Other Guardian Information?
Guardian Information
Guardian Name:
Guardian DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Guardian Address:

Street Address

Street Address Line 2

CityState

Zip Code
Guardian Phone No.:
Format: (000) 000-0000.
Is there a Delegation of Parental Authority (DOPA) in place?
Please upload a copy of the DOPA (if available)

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Siblings/Others in the Home - Names and Ages:

0/100
Reason for referral concerns urgent/safety issues?

0/130
What do you hope to accomplish through our services?

0/130
INSURANCE INFORMATION
Policy Holder:
Policy:
Group:
Insurance Phone #:
(000) 000-0000Format: (000) 000-0000.
Insurance Address:

Street Address

Street Address Line 2

CityState

Zip Code
Is this a court-ordered screening/assessment:
Legal:
On Probation. Agent Name:
List charges:
Legal and Physical custody of child is:

Other
Is this a standing custody order?
Upload custody order if available:

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School:
Attendance problems:
Behavior problems:
Decline in grades, failing:
List any counselor or teachers:
Special education services:
Is Individualized Education Plan (IEP) available?
Upload IEP if available:

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Consent for Release of Information

Click on this Release of Information link to access the Blue Earth County Consent for Release of Information
Fill out this BEC Release of Information form. The ROI form will be uploaded and attached to this form. Or, if you already have a filled BEC Human Services ROI, upload it below.
Upload Blue Earth County Human Services Release of Information form:

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Family:
Strengths:
Strained/problematic interactions:

0/100
Past services with Blue Earth County or other agencies:

0/100
Other Issues:
Peers:
Recent change in friends:
Becoming isolated:
Peers have CD issues:
Other documents to include:
- Updated Diagnostic Assessment (within 180 days)
- CASII
- Recommendation of Children’s Mental Health Case Management
Upload additional documents here:

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Mental Health/Medical:
Current doctors:
Past MH services:
Current MH services:
Other Service providers:
Past/current diagnosis:
Current medications:
If uploading a list, please specify "see upload".
Upload medication list:

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Medication Compliance: Please check one:
- To review the information you entered or to retain a copy of your submitted form, please click on "Preview PDF" and print or download a copy of this form.
- To Save this form and continue filling and submit later, click on "Save and Continue Later". You will be required to enter or set up a Jotform account.
- Click on the "Submit" button to submit this form to Blue Earth County Human Services.
Due to HIPAA regulations, a PDF of this form cannot be sent via email.
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Children's Mental Health Intake Information