Please fill out the form below if you are interested in Northland Counseling Center’s BHH program! BHH Consent Todays Date MM slash DD slash YYYY Is this a referral for yourself?* Yes No Clients Name First Last Date of Birth for Client MM slash DD slash YYYY If client is under the age of 18, please indicate the guardians name: First Last Client/Guardian Phone NumberPlease indicate if it is okay to leave a message at the number listed: Yes No Please indicate if it is okay to receive text messages from Northland Counseling Center. Yes No Referral Source Name and Agency:If you are a referring agency please have the client sign a Release of Information and fax to 218-999-4041.If you are a referring agency please have the client sign a Release of Information and fax to 218-999-4041. Consent* I agree that all information that is provided is true and correct to the best of my knowledge.By checking this box I am indicating that all information is true and correct to the best of my knowledge.