If you are scheduled for an intake appointment at Family Connections, please click on each form on the left to open the document and print.
There are two forms available. One is designed for you to type in your information directly onto the computer and then print The second form is designed for you to print them off and complete with a pen or pencil. You decide which option works best for you. Please read each form carefully, sign and bring them with you.
* Please note that on the Patient Care Form, you need to only complete the bottom portion of the form and please indicate the name of the doctor on the top of the page. Insurance companies ask for mental health providers to send treatment plans to primary care physicians. This form is an alternative to sending detailed information. You have the option of indicating you do not wish for this form to be sent. I simply need to indicate your decision in my case file.
Counseling & Financial Agreement
Bill of Rights
Limits of Confidentiality
Notice of Privacy Practices Info
Acknowledgement of Notice of Privacy Practices
Patient Care
Service Fees
For Children Only
Mental Health Functioning
Print &
Forms Complete Complete w/
on Computer Paper or
& Print PencilClick on link to the left to make a payment in amount of $251.19. Please note there is an additional 3% charge when paying online to cover the paypal fee
11708 Wayzata Blvd
Minnetonka, MN 55305
ph. 952-544-0964
fax. 952-544-6405
joyce_arendt@msn.com
Click on link to the left to make a payment in amount of $60.00. Please note there is an additional 3% charge when paying online to cover the paypal fee.
If you are a client and are paying an invoice or co-pay generated by Family Connections. Please scroll down to the bottom of this page and click on the purple "Buy This" button. You will need to pay through your own paypal account. If you don't have a paypal account or need to pay using a tax credit card, then find the dollar amount you owe and click on the square buy this button. If are unable to locate your payment amount, please contact Family Connections to have your amount added
Click on link to the left to make a payment in amount of $35.00. Please note there is an additional 3% charge when paying online to cover the paypal fee.
Click on link to the left to make a payment in amount of $30.00. Please note there is an additional 3% charge when paying online to cover the paypal fee.
Click on link to the left to make a payment in amount of $20.00. Please note there is an additional 3% charge when paying online to cover the paypal fee.
Click on link to the left to make a payment in amount of $25.00. Please note there is an additional 3% charge when paying online to cover the paypal fee.
Click on link to the left to make a payment in amount of $76.46 Please note there is an additional 3% charge when paying online to cover the paypal fee.
Click on link to the left to make a payment in amount of $40.00 Please note there is an additional 3% charge when paying online to cover the paypal fee.
Click on link to the left to make a payment in amount of $106.00. Please note there is an additional 3% charge when paying online to cover the paypal fee.
. . . Restorative Healing for All Generations
Click on link to the left to make a payment in amount of $160.00. Please note there is an additional 3% charge when paying online to cover the paypal fee.
Click on link to the left to make a payment in amount of $25.00. Please note there is an additional 3% charge when paying online to cover the paypal fee.
