Please fill out the form below if you are interested in Northland Counseling Center’s Behavioral Health Home (BHH) program! BHH Date MM slash DD slash YYYY Please tell us what location you are referring to: Grand Rapids Office (Itasca County) Hibbing Office (Northern St. Louis County) International Falls (Koochiching County) I am not sure Please tell us the relationship to the person you are making the referral for: Parent Guardian Agency who works with individual Self Other If you are a referring agency, please have the client sign a Release of Information and fax to 218-999-4041 for Grand Rapids or 218-283-3386 for IFalls & Hibbing.Referral Source and Contact Information:If you are a referring agency, please have the client sign a Release of Information and fax to 218-999-4041 for Grand Rapids or 218-283-3386 for IFalls & Hibbing.Name of person being referred:(Required) First Last Date of Birth for the person being referred:(Required) MM slash DD slash YYYY If client is under the age of 18 or if they are an adult with a guardian, please indicate the parent/guardian's name: First Last Client's Email, if known: Client or parent/guardian phone number:(Required)Reason for Referral or Helpful Information (for example, the client's current team members).Consent(Required) By checking this box I am indicating that all information is true and correct to the best of my knowledge, and client has given permission to be referred. Call 218-999-4020 for details on program.
