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4600 18th Ave NW
Rochester, MN 55901


1625 Highway 14 East
Rochester, MN 55904

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Monday - Thursday: 8:00 AM - 5:00 PM
Friday: 8:00 AM - 3:00 PM
(Evenings By Appointment)
Saturday - Sunday: Closed

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Thank you for visiting our website. Please use this form to request more information, request an appointment, or provide feedback about our services. Click on the "SUBMIT" button when you are ready to send. We look forward to hearing from you!

Client Name *:
Date Of Birth:
Address *:
Apt/Suite #:
City *:
State / Province *:
ZIP / Postal Code *:
Phone *:
Email *:
Marital Status:
Primary Language:
Other Language:
Military Status:
Military Branch (if applicable):
If other, please specify:
Highest Education Level:
Household Income:
Household Size *:
Have you or another member of your household received services from FSR before?:
Referral Source:
I am interested in the following services:

Emergency Contact #1
First Name *:
Last Name *:
Phone *:
Relation *:

Relative Contact #2
First Name:
Last Name:
State / Province:
ZIP / Postal Code:

Information about Others (spouse, children, significant other) in household:
First Name:
Date Of Birth:

Health Information
Important present/past illness, allergies, infectious diseases (optional), injuries, or handicap
Name Of Doctor:
List of medications you are currently taking:
Would you like us to coordinate care with above named providers?:
Nicotine Use?:
If yes how much?:

Family History
Were your parents separated or divorced?:
If yes, how old were you?:
If you were raised by anyone other than your own parents, briefly explain:
How many brothers do you have?:
List all their ages:
How many sisters do you have?:
List all their ages:
Has anyone in your family had problems with mental illness?:
If yes, please explain:

Alcohol/Chemical/Nicotine use History
Do you have a family history of alcohol/chemical abuse?:
Have you ever been concerned about your alcohol/chemical use?:
Have you ever used more chemicals than you intended to?:
Have you experienced legal problems or loss of job due to chemical use?:
Have you been confronted by someone on your use?:
What is your history of Nicotine use?:

Alcohol/Chemical History
Have you ever had physical discomfort from chemical use (e.g., shakes, hallucinations, or blackouts)?:
Have you tried to control and/or stop your using?:
Have you ever received treatment for chemical abuse or dependency? :
When & Where?:

Please answer the following questions
Do you have concerns about your ability to parent?:
Have you ever been concerned about your temper?:
Have you ever been depressed? :
Have you ever had psychotherapy or counseling? :
Do you have concerns about your sexuality? :
Have you ever been physically abused? :
Have you ever been sexually assaulted?:
Have you ever been abused by your partner?:
Have you ever abused your partner? :
Have you ever attempted suicide?:
Have you ever had/have legal concerns?:
Have you been hospitalized for emotional/mental illness?:
Do you have concerns about gambling? :
Do you have concerns about eating?:
Do you have concerns about self-harm?:
Have you ever experienced a traumatic event?:

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