Forms

Intake Questionnaire *ONLY NEEDED IF YOU HAVE NEVER SEEN REBECCA MOORE*

Please complete this basic information if you have never been seen by Rebecca Moore. Thank you!

Informed Consent for Mental Health Treatment (rev 6-9-2026)

This document provides information on policies and practices at Moore Hope Mental Health

Bill of Rights

This form explains your rights while being treated by Moore Hope Mental Health.

Authorization to allow exchange of records or other communication with any other individual or group

Complete this form for any other parties with whom records/discussion of your care may need to occur

*ONLY IF YOU SAW ME IN MANKATO* Authorization to obtain records from Mankato Mental Health Associates

Please complete and return to release records of care from Rebecca Moore at Mankato Mental Health

*ONLY IF YOU SAW ME AT MADELIA HEALTH* Authorization to obtain records from Madelia Health

This form will allow release of records of care by Rebecca Moore while at Madelia Health

*MUST DO* Signature page for Informed Consent Document

Please sign and return attesting that you received and agree to these policies related to your care.

*MUST DO* Signature page for Bill of Rights form

Please sign and return indicating that you received and understand the Bill of Rights form.

*MUST DO* Informed Consent for Telehealth (virtual) appointments

Please sign and return that you agree to special aspects of care related to Telehealth visits

*MUST DO* Client Contact Information and Consent for Third Party Billing

Please complete this form and return.