Thank you for choosing Northland Counseling Center, Inc! We have offices in International Falls, Grand Rapids, Hibbing & Aitkin. If you are in need of immediate assistance or feel you are having a mental health emergency please call 911, 211 or NCC Grand Rapids area Crisis at 218-256-2659 or go to your local emergency room.
As part of Northland Counseling Center, Inc intake process we need to collect certain information and documents. In order to schedule you for an initial appointment we need to collect the following paperwork. Annually, thereafter; we will ask that you fill out the paperwork in order to update our records. If, at any time, you have questions on the paperwork or want to know why the information is needed please feel free to call 218-326-1274 and ask to speak to intake.
NOTE:
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.
SMARTPHONE USERS:
If you are completing these documents on a smart phone please use the ‘desktop‘ version otherwise forms may not submit and it may require you to resubmit all of your information. We apologize for the inconvenience.
- Adult Registration Form
- Adult Health Questionnaire
- 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
Release of Information
If you would like a family or friend involved in your mental health care, please fill out this form: Family & Friends Release of Information
You will need one form per person involved in your care. This form is optional.
In order to best help provide services please fill out a Release of Information for the following:
- Previous Mental Health Providers, if applicable
- Pharmacy Utilized
- Primary Health Care Clinic
If you fill out your paperwork and do not hear back from someone in our intake department within 48 hours (this does not include weekends or holidays), please call 218-326-1274.
