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Click on a form title to open a PDF document of that form. You will need Adobe Reader to view and print these documents. It's FREE and you can get it by clicking the button: 
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Forms |
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To request records from MPR or to authorize MPR to request records from another provider:
 Authorization to Release Information
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When joint legal custody is shared between parties not living in the same home:
Permission for Child Therapy
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When someone other than the client or an insurance company is paying for visits to MPR:
Third Party Payor Agreement
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To review Minnesota Psychological Resources’ Privacy Practices:
MPR Notice of Privacy Practices brochure
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New Client Paperwork
You are asked to arrive to your first appointment 15-20 minutes early to complete necessary paperwork prior to your visit. You also have the option of printing the new client paperwork at home and bringing the completed paperwork to your first appointment. |
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Please note: if you complete the paperwork outside of our office and fail to bring it to your first appointment, you will be asked to complete the paperwork at our office.
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1. Please complete the appropriate New Client Paperwork Packet:
New Therapy Client Paperwork (For clients seeing a therapist for talk therapy)
New Psychiatry Client Paperwork (For clients seeing a psychiatrist for medication management)
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2. Please complete the appropriate Agreement Authorization:
Insurance Agreement Authorization (If MPR will be billing your insurance company)
Self Pay Agreement Authorization (If MPR will not be billing your insurance company)
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3. For Medica or United Health Care members only:
UBH Wellness Assessment - Adult
UBH Wellness Assessment - Child or Youth
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