Below you will find forms in .pdf format for use at FTI Midwest listed by category. Please download the forms you need by clicking on the lines below. Fill them out and return them to FTI Midwest at your next appointment. If you need to download Adobe Reader, click on the Adobe icon on the left side of this page.

Intake and Consent to Treat Forms

These forms for for adults and children and must be completed before you begin your intake appointment at FTI Midwest for each person for whom a chart will be opened.

FTI Adult Intake and Consent Forms

FTI Child Intake and Consent Forms

Release of Information Forms

This form is for clients who need to have
FTI Midwest release information TO OTHER AGENCIES. You will also need to sign a release at the other agency for them to communicate with us. Some of these forms are listed below.

FTI Release Form

These forms are for clients who need to have
other agencies release information to FTI Midwest.

Douglas County Youth Servcies (JDC)

Bert Nash Community Mental Health Center


Marital Questionnaires

These forms are used by FTI Midwest therapists when diagnostic issues are in part the result of maritial disharmony. Individuals bringing a spouse to their sessions may wish to complete the following instruments and bring them to the first session:

Test 1: The Locke-Wallace Relationship Adjustment Test

Test 2: Weiss-Cerretto Relationship Status Inventory

Test 3: Areas of Disagreement Form

Test 4: Enjoyable Conversations

Test 5: Sound Marital House