--- title: Child Adolescent Mental Health intake forms description: The forms necessary for a child or adolescent seeing Mary Andersen as a patient | Mental Health Minnesota --- [![Mandersen 2017 primary website front logo1.1.png](https://www.maryaprn.com/hs-fs/hubfs/Header_Banner/Mandersen%202017%20primary%20website%20front%20logo1.1.png?width=1260&height=672&name=Mandersen%202017%20primary%20website%20front%20logo1.1.png "Mandersen 2017 primary website front logo1.1.png")](https://www.maryaprn.com) ## The following forms are necessary for your next visit (as per instruction from Mary Andersen) - Client Demographics:    [![.pdf_logo-resized-600.jpg](https://www.maryaprn.com/hs-fs/file-28558783-jpg/2014/.pdf_logo-resized-600.jpg?width=63&height=54&name=.pdf_logo-resized-600.jpg)](https://www.maryaprn.com/hubfs/2016_forms/INITIAL_CLIENT_INFORMATION__APPS_2016.pdf)    [![child client intake page](https://www.maryaprn.com/hs-fs/file-28559713-jpg/2014/word_icon-resized-600.jpg?width=63&name=word_icon-resized-600.jpg "child client intake page")](https://www.maryaprn.com/hubfs/2016_forms/INITIAL_CLIENT_INFORMATION__APPS_2016.docx) - Email Communication form    [![Email Communication form](https://www.maryaprn.com/hs-fs/file-28558783-jpg/2014/.pdf_logo-resized-600.jpg?width=63&name=.pdf_logo-resized-600.jpg "Email Communication form")](https://www.maryaprn.com/hubfs/2016_forms/Consent_for_Electronic_Communication_apps_2016.pdf)   [![email consent form](https://www.maryaprn.com/hs-fs/file-28559713-jpg/2014/word_icon-resized-600.jpg?width=63&name=word_icon-resized-600.jpg "email consent form")](https://www.maryaprn.com/hubfs/2016_forms/Consent_for_Electronic_Communication_apps_2016.docx) - Permission form    [![.pdf_logo-resized-600.jpg](https://www.maryaprn.com/hs-fs/file-28558783-jpg/2014/.pdf_logo-resized-600.jpg?width=63&height=54&name=.pdf_logo-resized-600.jpg)](https://www.maryaprn.com/hubfs/2016_forms/PERMISSION_STATUS_June_apps_2016.pdf)    [![Permission form](https://www.maryaprn.com/hs-fs/file-28559713-jpg/2014/word_icon-resized-600.jpg?width=63&name=word_icon-resized-600.jpg "Permission form")](https://www.maryaprn.com/hubfs/2016_forms/PERMISSION_STATUS_June_apps_2016.docx) - Consent for Email form    [![.pdf_logo-resized-600.jpg](https://www.maryaprn.com/hs-fs/file-28558783-jpg/2014/.pdf_logo-resized-600.jpg?width=63&height=54&name=.pdf_logo-resized-600.jpg)](https://www.maryaprn.com/hubfs/2016_forms/Consent_for_Electronic_Communication_apps_2016.pdf)    [![client consent form](https://www.maryaprn.com/hs-fs/file-28559713-jpg/2014/word_icon-resized-600.jpg?width=63&name=word_icon-resized-600.jpg "client consent form")](https://www.maryaprn.com/hubfs/2016_forms/Consent_for_Electronic_Communication_apps_2016.docx) - Symptom checklist    [![symptom checklist](https://www.maryaprn.com/hs-fs/file-28558783-jpg/2014/.pdf_logo-resized-600.jpg?width=63&name=.pdf_logo-resized-600.jpg "symptom checklist")](https://www.maryaprn.com/hubfs/2016_forms/symptom_checklist_2016.pdf)    [![symptom checklist](https://www.maryaprn.com/hs-fs/file-28559713-jpg/2014/word_icon-resized-600.jpg?width=63&name=word_icon-resized-600.jpg "symptom checklist")](https://www.maryaprn.com/hubfs/2016_forms/symptom_checklist_2016_1.0.docx) - Med Checklist    [![med checklist](https://www.maryaprn.com/hs-fs/file-28558783-jpg/2014/.pdf_logo-resized-600.jpg?width=63&name=.pdf_logo-resized-600.jpg "med checklist")](https://www.maryaprn.com/hubfs/docs/Current_and_Past_Medication_Checklist_APPs_2019.final-1.pdf)    [![med checklist](https://www.maryaprn.com/hs-fs/file-28559713-jpg/2014/word_icon-resized-600.jpg?width=63&name=word_icon-resized-600.jpg "med checklist")](https://www.maryaprn.com/hubfs/docs/Current_and_Past_Medication_Checklist_APPs_2019.final-1.docx) - Strength and Difficulty questionaire for **Ages 4-10**   [![.pdf_logo-resized-600.jpg](https://www.maryaprn.com/hs-fs/file-28558783-jpg/2014/.pdf_logo-resized-600.jpg?width=63&height=54&name=.pdf_logo-resized-600.jpg)](https://www.maryaprn.com/hubfs/2016_forms/SDQ-ages_4-10_Parent_2016.pdf)  [![Strength Difficulty questionnaire](https://www.maryaprn.com/hs-fs/file-28559713-jpg/2014/word_icon-resized-600.jpg?width=63&name=word_icon-resized-600.jpg "Strength Difficulty questionnaire")](https://www.maryaprn.com/hubfs/2016_forms/SDQ-ages_4-10_Parent_2016.docx)    - Strength and Difficulty questionaire for **Ages 11-17**    [![.pdf_logo-resized-600.jpg](https://www.maryaprn.com/hs-fs/file-28558783-jpg/2014/.pdf_logo-resized-600.jpg?width=63&height=54&name=.pdf_logo-resized-600.jpg)](https://www.maryaprn.com/hubfs/2016_forms/SDQ-ages_11-17_Parent_2016.pdf) [![Strength Difficulty questionnaire](https://www.maryaprn.com/hs-fs/file-28559713-jpg/2014/word_icon-resized-600.jpg?width=63&name=word_icon-resized-600.jpg "Strength Difficulty questionnaire")](https://www.maryaprn.com/hubfs/2016_forms/SDQ-ages_11-17_Parent_2016.docx) ## If you have any questions, please feel free to fill out a form on any of our pages or call us at 952-322-8532 ## Child / Adolescent Intake forms Remember: - Print out these forms - Have them filled out before you arrive - As always, come ready to ask questions - [Home](https://www.maryaprn.com/) - [Intake forms](https://www.maryaprn.com/intake/) - [Location Maps](https://www.maryaprn.com/intake/maryaprn-map/) - [Education Adult](https://www.maryaprn.com/education/) - [Additional Resources](https://www.maryaprn.com/helpful-numbers/additional-resources/) - [Mental Health Blog](https://www.maryaprn.com/blog/) - [Screening Tools](https://www.maryaprn.com/http://www.maryaprn.comscreening-tools/) Medical Disclaimer: All services are provided at our clinic, and not by email. If you need medical assistance, please call our clinic or visit us in person. The information provided on this web site is for informational purposes only. 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