Thank you for choosing Northland Counseling Center, Inc! Please complete the below form 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 Registration Form
- Provider Supervision Form
- Medicare Beneficiary Notice– If you have Medicare as an insurance plan, please review
We have been notified of a few issues with form submissions, We apologize for any inconvenience. This is currently being worked on. If you fill out the information below; please make sure you click yes to the hipaa privacy statement and the RED submit button. If there is an issue, please email firstname.lastname@example.org with a picture or description of the error that occurred. We are working on correcting the issue. Thank you!
if the page is blue, scroll to the bottom and click on desktop version. otherwise, the page will not submit.