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Records Request

For the release of records, there needs to be both a release and a request.  Releases need to be signed by the client, in person at one of our offices so they can be verified by one of our staff.  If there is a release on file, other entities may us the paperwork below to fax a request for records to 507-388-3199.

Referrals
Additional Information
Telehealth Mental Health Services:

In order to be seen via HIPAA compliant method of live, two-way interaction between the client and provider using audio-visual technology or phone call for the delivery of mental health services to and from remote locations, this Consent needs to be signed and returned to Southern Minnesota Behavioral Health prior to the first session.

  • Informed Consent for Telemental Health Services
  • Emergency Contact Form
  • Referral Form
  • HIPAA Notice of Privacy
Requesting Records:

For the release of records, there needs to be both a release and a request.  Releases need to be signed by the client, in person at one of our offices so they can be verified by one of our staff.  If there is a release on file, other entities may us the paperwork below to fax a request for records to 507-388-3199.

  • Request For Medical Records
  • Request by Client or Legal Representative to Access Medical Record
  • Consent for the Release of Information
Intake Packets for Initial Appointment:
  • Payment for Services Client Consent Form
  • Consent for Treatment
  • Child Questionnaire
  • Adult Questionnaire
  • Strengths and Difficulties Questionnaire 4-10
  • Strengths and Difficulties Questionnaire 11-17
  • Strengths and Difficulties Questionnaire P11-17
  • Payment for Services Spanish Consent Form
Critical Links to Explore:
Our Domestic Abuse Intervention Program (DAIP) focuses on treating male offenders of domestic violence using the Duluth Model. Domestic violence assessments may also be completed. Additionally, anger management services are available for teens and adults.
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