Client portal Todays Date MM slash DD slash YYYY Clients Name (if client is a child, please put child's name)* First Last Date of Birth for Client MM slash DD slash YYYY Last 4 digits of client's social security number*PhoneEmail to send verification code* Enter Email Confirm Email If client is under that 18, Parent/Guardian Name First Last Date of birth parent/guardian MM slash DD slash YYYY Consent – Please sign the bottom of the form before submitting.* I agree to receiving emails from crediblebh and I understand that by having accessing to credible portal that I have read the terms and condition listed on Northland Counseling Center website.
