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Complete forms online
Every form below can now be completed and submitted directly on this site — no printing required. Prefer paper? Each card also links to the original PDF.
Outpatient & In-Home Family Based Services Referral
Referring workers, agencies, or family members submit this form to refer a client and family to Therapeutic Services Agency for Family Based Services (FBS) or Outpatient counseling services.
Day Treatment Referral
Completed by a referral source (school contact, clinician, or other provider) to refer a client to TSA's Day Treatment program at the Pine City or North Branch location.
School Based Mental Health Services Referral
Completed by school staff to refer a student and their family to TSA's School Linked Mental Health Services.
Deaf/Hard of Hearing and DeafBlind Services Referral
Professionals, agencies, or family members submit this form to refer a client to Therapeutic Services Agency's Deaf/Hard of Hearing and DeafBlind Services program serving Out-State Minnesota.
Billing Release & Consent to Treatment
Clients (or their legal representatives) complete this form before beginning services to acknowledge receipt of TSA's privacy and office policy notices and to authorize treatment and payment.
Child/Adolescent History Questionnaire
A parent or caregiver completes this questionnaire before a child or adolescent begins services, giving the therapist a full picture of the child's family, development, health, school, and behavioral history (adolescents ages 12-18 complete the substance use and PHQ-9 sections themselves).
Consent for Release of Information
Clients of Therapeutic Services Agency, Inc. (TSA) — or their legally authorized representatives — submit this form to authorize TSA to release protected health information to, or receive it from, another individual, agency, or clinic.
Notice of Privacy Practices — Acknowledgment
By signing below, you acknowledge that you have received and reviewed the Therapeutic Services Agency, Inc. Notice of Privacy Practices.
Office & Financial Policy Agreement — Acknowledgment
By signing below, you acknowledge your agreement to the Therapeutic Services Agency, Inc. (TSA) Office and Financial Policy Agreement and confirm you have reviewed the Client Bill of Rights; this signature page will become a part of your health record.
Minors Consent for Health Care
This is an informational notice (August 2023) with nothing to fill out, provided to minor patients and their parents or guardians to explain when Minnesota law permits a minor to consent to health care services on their own.
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No one is denied access to services due to an inability to pay. Reach out — we're here to help you find a path forward.