Adult Health Questionnaire

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
PHQ-9
GAIN-SS
GAD-7
WHODAS
Provider Supervision Form
Medicare Beneficiary Notice– If you have Medicare as an insurance plan, please review
Missing Appointment Policy

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 bworrath@northlandcounseling.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.

Adult Health Questionnaire NEW

Intake Questionnaire:
Today's Date:
MM slash DD slash YYYY
Location for which you would like your services at:
- Grand Rapids
- Hibbing
- Aitkin
- International Falls
Client Name:
First Middle Last
Address:
Street Address City State / Province / Region ZIP / Postal Code
Primary Phone:
May we leave a voice message or text:
- Yes
- No
Email:
Gender:
- Male
- Female
- Transgender
- Other
Date of Birth:
MM slash DD slash YYYY
Age:
Social Security Number:
Race:
- Asian
- Black/African American
- Native Hawaiian
- White
- Other
- American Indian / Alaskan Native
If your race is Native American / Alaskan Native please indicate Tribal Enrollment:
Ethnicity:
- Central American
- Cuban
- Dominican
- Puerto Rican
- South American
- Other
If you are Hispanic/Latino, Please indicate one of the following:
Hair Color:
Length:
- Short
- Medium
- Long
Eye Color:
Do you wear...
- Eye Glasses
- contacts
- Neither
Height:
Weight:
Military Service:
- Non-Vet
- Vietnam Vet
- Other Vet
- Disabled
- I did NOT serve in the Military
If you did serve, what Branch:
Do you have a health care directive?
- Yes
- No
- I do not know
Emergency Contact:
Emergency Contact Name:
First Last
Emergency Contact Address:
Street Address City State / Province / Region ZIP / Postal Code
Emergency Contact Phone Number:
Relationship:
Reason for Visit:
Tell us who referred you:
- Self-Referred
- Referred by a Health Care Provider / Mental Health Provider
- Court
- Chemical Dependency / Drug Court
- Employment Requirement
- Other
Please explain the reason(s) you are seeking mental health services:
Current Life Situation:
Marital Status:
- Single / Never Married
- Married
- Divorced
- Re-Married
- Separated
- Living with significant other (boyfriend/girlfriend/fiancé)
Where do you live?
- Apartment
- House
- Residential Facility / Community Residential Setting
- Homeless
- Other
Who do you reside with?
- Alone
- Spouse
- Parents
- Children
- Friends
Name of other individuals in the house:
First Last
Relationship:
Age:
Name of other individuals in the house:
First Last
Relationship:
Age:
Name of other individuals in the house:
First Last
Relationship:
Age:
Name of other individuals in the house:
First Last
Relationship:
Age:
Name of other individuals in the house:
First Last
Relationship:
Age:
Name of other individuals in the house:
First Last
Relationship:
Age:
How would you describe your living situation?
- Excellent
- Good
- Okay
- Poor
Income and Employment:
Current Source of Income:
- Wages
- Social Security
- Pension
- MFIP
- Child Support
- Other
Employment:
- Full-Time
- Part-Time
- Seasonal
- Self-Employed
- Disabled
- Retired
- Unemployed
- Student
Employer's Name:
Occupation:
Education History:
Education:
- Currently in Grade School, Middle School or High School
- GED
- High School / Diploma
- Vocational Certificate
- Some College
- College Graduate
- Post Graduate
- Did NOT complete school
Degree OR Current Grade of school currently enrolled in:
Highest High School Grade Completed:
Did you receive Special Education Services?
- Yes
- No
- I am NOT sure
If you answer 'yes' to receiving Special Education Services, Please tell us what services (IEP, 504) and why:
Barriers to learning or past school testing:
Additional Comments / Information about Educational Barriers or Educational History:
Symptoms / Relevant History (Northland will NOT be contacting other providers unless given permission):
Have you completed a diagnostic assessment (DA) within the past year:
- Yes, please see below
- No
- I am NOT sure
Agency:
Agency Dates
Have you ever received Mental Health (Therapy) Services in the past?
- Yes, please see below
- No
- I am NOT sure
Agency:
Agency Dates
Agency:
Agency Dates
Have you ever received Medication Management from a Psychiatrist or Nurse Practitioner?
- Yes, please see below
- No
- I am NOT sure
Agency:
Agency Dates
Agency:
Agency Dates
Early Childhood Developmental Concerns:
Do you have concerns with development, nutrition and/or social concerns, please indicate concerns in as much detail as possible:
Normal Birth?
- Yes
- No
Please list any birth complications or birth defects:
Were early childhood milestones met on time?
- Yes
- No
Please list any developmental delays (walking, talking, dressing, toileting, etc):
Please list any special needs in childhood:
Substance or Alcohol Abuse History (Northland will NOT contact any providers unless given permission):
Have you ever participated in Substance Abuse Treatment?
- Yes, please see below
- No
- I am NOT sure
Agency:
Agency Dates
Agency:
Agency Dates
Do you feel you have a problem with substances and/or alcohol?
- Yes
- No
- I am NOT sure
If yes, do you want help with substance use?
- Yes
- No
- I am NOT sure
Do you use nicotine?
- Yes
- No
If yes, what type of nicotine do you currently use AND how much do you currently use?
Is there a family history of substance use?
- Yes
- No
If yes, please tell us who in your family has a history of substance use and what type of substance (ex: mother / alcohol):
Do you consume Caffeine?
- Yes
- No
Type and daily caffeine consumption quantity (ex. coffee / 1 pot daily):
Medical (Northland will NOT contact any providers, unless given permission)
Primary Care Provider Name:
Primary Care Clinic or Hospital:
Preferred Pharmacy:
Are you undergoing any current treatment for any medical condition/infection?
- Yes
- No
If yes, please indicate the condition and current treatment:
Do you have any past medical conditions and/or have you undergone any surgeries:
- Yes
- No
If yes, please indicate past surgeries and/or medical conditions you have recieved treatment for:
Please tell us about any medical conditions that run in your family (diabetes, heart disease, cancer, etc):
Date of last physical exam, if known:
MM slash DD slash YYYY
If date of physical exam is unknown, please estimate a time frame:
- Within the past month
- Within the past six months
- Over a year ago
- Over 5 years ago
Do you have Allergies (seasonal, latex):
- Yes
- No
Please list your Allergies and the reaction you experience:
Have you had your thyroid checked?
- Yes
- No
Do you have a thyroid condition?
- Unknown
- Never been checked
- Normal
- Hypothyroidism
- Hyperthyroidism
If known, what is the Date of your past thyroid check?
MM slash DD slash YYYY
Family history of thyroid issues?
- Yes
- No
If yes, please explain. (ex. mother / hypothyroid)
Head/Brain injuries, seizure, stroke, concussion or loss of consciousness?
- Yes
- No
If yes, please explain:
Do you have pain which interferes with daily activities?
- Yes
- No
If yes, please list:
Have you experience any recent significant weight gain/loss?
- Yes
- No
If yes, how much weight gain/loss and reason if known:
Do you eat regular meals?
- Yes
- No
Describe a daily meal schedule:
Do you exercise?
- Yes
- No
Please tell us more about your current exercise routine:
Are you currently disabled?
- Yes
- No
Please tell us more about your disablity:
Medication:
Please list your current medications (include the name and dose, if known):
Do you have any Medication Allergies?
- Yes
- No
If yes, please list your Medication Allergies:
Have you experienced any medication side effects:
- Yes
- No
If yes, please list the medication and the side effect you experienced:
Are you currently utilizing any Supplemental Medicinal Treatment (St. Johns wort, herbs, vitamins):
- Yes
- No
Please list any types of medicinal treatment used (St. Johns wort, herbs, vitamins):
Women:
Are you currently pregnant?
- Yes
- No
Due Date:
MM slash DD slash YYYY
Do you experience regular periods?
- Yes
- No
If no, please explain:
Additional Information:
If there are any additional comments please let us know:
In order to decrease the chances of a conflict of interest for our staff, if you know of anyone recieving services through Northland Counseling Center can you please tell us their name and your relationship to them:
Person who is filling out this form
First Last
By checking this box you are acknowledging that all information presented is true to the best of your knowledge. Please sign the bottom of the form before submitting, Thank You - Northland Counseling Intake Staff!
I agree that all information is true and correct
If you do not receive a call from a staff within 2 days of submitting your paperwork please contact your local Northland Counseling Center location to ensure they have received your paperwork. Please ensure you click submit.

Adult Health Questionnaire NEW

Intake Questionnaire:

Emergency Contact:

Reason for Visit:

Current Life Situation:

Income and Employment:

Education History:

Symptoms / Relevant History (Northland will NOT be contacting other providers unless given permission):

Early Childhood Developmental Concerns:

Substance or Alcohol Abuse History (Northland will NOT contact any providers unless given permission):

Medical (Northland will NOT contact any providers, unless given permission)

Medication:

Women:

Additional Information:

Location & Hours

Get in Touch

Complete Continuum of Care

Adult Health Questionnaire NEW

Intake Questionnaire:

Emergency Contact:

Reason for Visit:

Current Life Situation:

Income and Employment:

Education History:

Symptoms / Relevant History (Northland will NOT be contacting other providers unless given permission):

Early Childhood Developmental Concerns:

Substance or Alcohol Abuse History (Northland will NOT contact any providers unless given permission):

Medical (Northland will NOT contact any providers, unless given permission)

Medication:

Women:

Additional Information:

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Location & Hours

Get in Touch

Complete Continuum of Care