Make a Referral

If you would like to make a referral to Northland Counseling Center, Inc please fill out the below form. Please do NOT use this for crisis referrals. Please note, not all services are available in all locations; however, due to expansion of telehealth services we are able to increase our availability of services to individuals and families.

If you have a release of information signed by the person you are referring to Northland Counseling Center, please fax it to:

For Grand Rapids, Hibbing & Aitkin Locations : 218-327-8997

For International Falls Location : 218-283-3386

Please notify the individual you are referring that someone from Northland Counseling Center, Inc. will be reaching out to them. (Please allow up to 3 days, not including weekends and holidays).

If this is an emergency, please contact our Crisis Services at:

Itasca County: 218-256-2659 (Northland Counseling Center Crisis) for Itasca County Crisis Services: 211

Koochiching County: 211

For Aitkin and St. Louis County please contact 211 to be dispatched to your local crisis response services

Initial Referral Form

Initial Referral Summary

Referral Source Name
Referral Source Agency
Referral Source Email
Do you have a Release of Information Signed?
- Yes
- No
If yes, please fax to: Aitkin Office: 218-327-8997 Grand Rapids Office: 218-327-8997 Hibbing Office: 218-327-8997 International Falls: 218-283-3386
What location are your referring to for services?
- Aitkin Area
- Grand Rapids Area
- Hibbing Area
- International Falls Area
What services are you referring for:
- Medication Management *
- Individual Therapy *
- ARMHS *
- Peer Support *
- Housing
- Childrens Day Treatment
- Adult Mental Health Case Management
- Children's Mental Health Case Management
- Kiesler Wellness Center
- Hardwig House
- Northern Opportunity Works (NOW)
- Behavioral Health Homes - BHH
- Housing Supports
- Children's Therapeutic Supports and Services (CTSS) *
- Children's Day Treatment
- Northland Recovery Center Services
Not ALL services are available in ALL areas. With Telehealth, we are able to off some services remotely via telehealth. Services marked with an * can be offered via telehealth to increase service delivery.
Who are you referring:
First Last
Date of Birth (If available)
MM slash DD slash YYYY
Mailing Address (if available)
Street Address City State / Province / Region ZIP / Postal Code
Home Phone
Cell Phone
If referral is under the age of 18 please identify primary parent / guardian name:
First Last
Relationship to the client:
Phone
If referral is under the age of 18 please provide a secondary parent / guardian name::
First Last
Relationship to the client:
Phone
Person Retaining Legal Custody, If Not a Parent
First Last
Relationship to the client:
Phone
Address of Person who has Legal Custody (if available)
Street Address City State / Province / Region ZIP / Postal Code
Phone # of Person who has Legal Custody
Comments
This field is for validation purposes and should be left unchanged.

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Northland Counseling Center, Inc.
Grand Rapids
Hibbing
International Falls
Kiesler Wellness Center
Aitkin

Northland Recovery Center, Inc.
Grand Rapids, MN
International Falls, MN

Northland Counseling Center Inc. does not discriminate in the provision of services to individuals based on their inability to pay, race, color, sex, national origin, disability, religion, or sexual orientation. It is the policy of Northland Counseling Center to provide essential medical services regardless of the patient’s ability to pay. Discounts are offered based upon household income and size. A sliding fee schedule is used to calculate the basic discount and is updated each year using the federal poverty guidelines. Northland Counseling Center Inc. accepts Medicare, Medicaid, private and CHIP. We will work with you to determine insurance eligibility.