Get In Touch

MAIN OFFICE

4600 18th Ave NW
Rochester, MN 55901

SOUTH OFFICE

1625 Highway 14 East
Rochester, MN 55904

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HOURS OF OPERATION

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

Call Us

507-287-2010

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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!

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Emergency Contact #1
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Relative Contact #2
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Health Information
Important present/past illness, allergies, infectious diseases (optional), injuries, or handicap
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Nicotine Use?:
If yes how much?:

Family History
Were your parents separated or divorced?:
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If you were raised by anyone other than your own parents, briefly explain:
How many brothers do you have?:
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Mother:
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Has anyone in your family had problems with mental illness?:
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Alcohol/Cllemical/Nicotine use History
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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
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Have you tried to control and/or stop your using?:
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Please answer the following questions
Do you have concerns about your ability to parent?:
Have you ever been concerned about your temper?:
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Have you ever had psychotherapy or counseling? :
Do you have concerns about your sexuality? :
Have you ever been physically abused? :
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Have you ever been abused by your partner?:
Have you ever abused your partner? :
Have you ever attempted suicide?:
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Do you have concerns about eating?:
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Have you ever experienced a traumatic event?:

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