Adult Client Registration

Thank you for choosing Northland Counseling Center, Inc! Please complete the below forms as part of our intake process or for our annual update. Any missing information may cause a delay in services. Along with this form please ensure you are also filling out these additional forms:

Adult Pre-Intake Questionnaire
PHQ-9
GAIN-SS
GAD-7
WHODAS
Provider Supervision Form
Medicare Beneficiary Notice– If you have Medicare as an insurance plan, please review

if the page is blue, scroll to the bottom and click on desktop version. otherwise, the page will not submit.

Client Registration Form

Today's Date

Client's Date of Birth

Phone

Client Legal Name

First Middle Initial Last

Contact email:

INSURANCE / INCOME:

If you currently have insurance please fill out the following information:

Primary Insurance Company Name

Insurance Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Group Number

ID Number

Insurancy Company Phone

Employer Name:

Subscriber Name

First Last

Subscriber Date of Birth

Subscriber Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Relationship to Client

Do you have a secondary insurance?

Yes

Secondary Insurance Company Name

Insurance Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Group Number

ID Number

Insurancy Company Phone

Employer Name:

Subscriber Name

First Last

Subscriber Date of Birth

Subscriber Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship to Client

If you do not have insurance and would like to fill out a sliding fee application check here:

Yes

If you would like more information about our sliding fee scale please call: *Aitkin, Grand Rapids, Hibbing: 218-326-1274, ask to speak to someone about the sliding fee application. *International Falls: 218-283-3406 ext 122, ask to speak to someone about the sliding fee application.

If you plan to use your employee EAP please check yes:

Yes

It is YOUR responsible to contact your EAP provider AND provide the authorization number prior to your appointment. If the information is NOT received you may be responsible for the payment of services.

RELEASE OF INFORMATION:

I have read and agree to the following:

I authorize Northland Counseling Center, Inc. (NCC) to release information to my insurance company regarding my treatment here. This could include my social security number, diagnosis, prognosis, dates of treatment, narrative notes and types of treatment and permit a facsimile or photographic reproduction of this authorization in place of the original. This is for the purpose of validating claims submitted to your insurance company. I also authorize to make payments to NCC for all insurance benefits to which I or my dependents are entitled for services received at NCC. I understand that my consent terminates one year from the date of signature, unless I choose to revoke it earlier.

I affirm that the information reported above is accurate and that the fee, payment method and release of information have been discussed. If my financial status changes, an update of this agreement may be renegotiated.

PAYMENT PLAN:

I have read and agree to the following:

□ Each month I will pay a minimum of 25% of the total balance due until all charges are paid.
□ Following each visit, I will pay the charges for that visit.
□ Upon receipt of a monthly statement, I will remit the amount due.
□ I will be responsible for payment for any services denied by my insurance company, including but not limited to deductibles, co-pays and exclusions.
□ I understand that I am responsible for the charges in full, forfeiting my opportunity to be placed on the sliding fee scale, if I do not comply with the following (when applicable):

a. Provide verification of income documentation
b. Obtaining a physician referral when my insurance requires one.
c. Applying for medical assistance and notifying Northland Counseling Center, Inc. (NCC) of disposition if referred.
d. A fee may be charged for any missed appointments which are not canceled at least 24 hours in advance.

I recognize that it is my responsibility to be aware of my insurance benefits and payment by insurance is not guaranteed.

In the event NCC has been unable to collect payment from me for services within a reasonable period of time, NCC then reserves the right to turn the account over to an attorney or collection agency (this may include: address; phone/cell phone number; email, etc.). I understand that interest, finance charges and other costs as allowed by law, will be added to my account. A 15% processing fee will be added to any account sent to collections.

MISSING APPOINTMENT POLICY:

Time is a valuable commodity at Northland Counseling Center and we dedicate time to your treatment and expect that you do the same. It is understandable that an appointment may need to be missed for planned or unplanned reasons. Please, notify us as soon as you are able when you realize you cannot attend a scheduled appointment. It is also important to be on time for an appointment as arriving late interferes with the therapeutic process and you may not be seen for your appointment. Most importantly, you are not able to benefit from therapy and/or medication management if tardiness or absences become frequent. We do our best to do reminder calls and texts and clients are ultimately responsible for remembering their appointments. By signing below, I agree to try my best to provide a 24-hour notice if I am to miss a scheduled appointment. I will not schedule an appointment at a time when I know I am not able to attend. I understand that two consecutive no-shows or frequent late cancelations may result in me being placed on the waiting list for an appointment. I understand I may be charged a fee, if I do not provide notice and/or show for my appointment.

Yes, I have read and understand.

HEALTH RECORD:

A health record location service helps my mental health providers determine where I have received care and obtain information about my health to help treat me. NCC may access my information in a record locator service to help provide care to me. NCC may share my health record and information with a record locator services unless I CHECK the box below. If I check the box below, I understand NCC will exclude my information in any record locator service.

Yes, I would like my information shared in a record locator services for care coordination reasons

No, I do not want my information shared in a record locator service

Telehealth Consent

By signing this form, I consent to the use of telehealth services for myself / child / dependent / person who I service as their guardianship of. You may obtain a copy of NCC’s telehealth information.

Uploaded Documents

Please upload a copy of the front and back of your insurance card or email a copy to: intake@northlandcounseling.org

Insurance 1

Max. file size: 300 MB.

Insurance 2

Max. file size: 300 MB.

Name of Person filling out form:

Please sign the bottom of the form before submitting (above the submit button), Thank you - Northland Counseling Intake Staff

Please take time to fill out Adult Pre-Intake Questionnaire, GAIN-SS, GAD-7, PHQ-9, WHODAS, Missing Appointment, Medicare Waiver and Release of Information forms for your intake to be complete.

Client Registration Form

INSURANCE / INCOME:

Telehealth Consent

Uploaded Documents

Please sign the bottom of the form before submitting (above the submit button), Thank you - Northland Counseling Intake Staff

Location & Hours

Get in Touch

Complete Continuum of Care

Client Registration Form

INSURANCE / INCOME:

Telehealth Consent

Uploaded Documents

Please sign the bottom of the form before submitting (above the submit button), Thank you - Northland Counseling Intake Staff

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Location & Hours

Get in Touch

Complete Continuum of Care