Where are you seeking services? *

You may select multiple locations if applicable.

Moorhead, MN

Detroit Lakes, MN

Breckenridge, MN

Fergus Falls, MN

Alexandria, MN

St. Cloud, MN

Fargo, ND

Bismarck, ND

Name (of new client) *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Phone *

We will use this number to contact you. Please ensure it is accurate.

(###)

###

####

How may we contact you?

Call me during Solutions office hours (typically 8am-5pm)

Please email me (at the email address listed below)

Please don't contact me, I will contact Solutions instead

If we can contact you by phone, may we leave a message?

Please note, for privacy purposes we can only do this if your voicemail includes your name.

Yes, you may leave me a message

No, please don't leave me a message

Do we have your permission to email you?

Your email address will only be used for appointments and other necessary communication.

Yes

No

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does the client have a legal guardian? *

Yes, client has a legal guardian

No, client does not have a legal guardian

If client is a minor or has a legal guardian, please describe the custody situation:

Biological parents are legally married and both have legal custody

Biological parents are divorced, and share legal custody

Only biological mother has legal custody

Only biological father has legal custody

Adoptive guardian has legal custody

Agency has legal custody

Other

Legal Guardian's Name

First Name

Last Name

Legal Guardian's Phone Number

(###)

###

####

Second Legal Guardian's Name

First Name

Last Name

Second Legal Guardian's Phone Number

(###)

###

####

How will you pay for services?

Insurance

Self-Pay (I will pay out of pocket)

Someone or an agency will pay for me

Policy Holder Date of Birth

MM

DD

YYYY

Secondary Insurance Policy Holder Date of Birth

MM

DD

YYYY

Guarantor name (if applicable)

If using a Guarantor, please identify his or her name, address, and the relationship with the client. This person would receive monthly statements if applicable. If you are not using a guarantor, please skip this section.

First Name

Last Name

Acknowledgement of Electronic Submission *

By clicking here, I acknowledge that this information will be e-mailed to a Solutions intake e-mail address. I am aware that while this method is secure to the best of our ability, there can be possible risk associated with electronically submitting personal information. I understand that I may alternatively bring this information directly to a Solutions clinic location to reduce risk.