Adult Registration Form

Please fill out the below form. When you are finished please complete the Adult Health Questionnaire, GAIN-SS, PHQ-9, WHODAS & GAD 7. Thank you for choosing Northland Counseling Center!

Today's Date
Date Format: MM slash DD slash YYYY
Location for which you would like your services?
- Grand Rapids
- Aitkin
- Hibbing
- International Falls
Client Legal Name
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
I authorize Northland staff to contact me at the above address
By checking the box you give permission.
Home Phone
Do you give consent to leave a message on your home phone?
By checking the box you give permission.
Work Phone
Do you give consent to leave a message on your work phone?
By checking the box you give permission.
Cell Phone
Do you give consent to leave a message on your cell phone?
By checking the box you give permission.
Do you give consent to text a message on your cell phone?
By checking the box you give permission.
Email
Do you give consent for Northland staff to email you?
By checking the box you give permission.
Date of Birth
Date Format: MM slash DD slash YYYY
Social Security Number
Sex
- Male
- Female
Primary Care Physcian or Clinic
Power of Attorney or Gaurdian Information
Name of Gaurdian or Power of Attorney
First Last
Best Phone Number to reach you
Do you give concent to Northland Staff to leave you a message?
By checking this box you give consent
Alternative Phone Number
Do you give concent to Northland Staff to leave you a message?
By checking this box you give consent
Email
Do you give consent for Northland staff to email you?
By checking the box you give permission.
I have Power of Attorney on behalf of the client above and will fax, email or mail in supporting documents.
By checking this box you are indicating that the above information is true.
I have Gaurdianship on behalf of the client above and will fax, email or mail in supporting documents from the courts giving me said Gaurdianship.
By checking this box you are indicating that the above information is true.
Insurance
Primary Insurance Company Name
ID Number
Group Number
Insurance Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurancy Company Phone
Subscriber Name
First Last
Subscriber Date of Birth
Date Format: MM slash DD slash YYYY
Employer of Subscriber
Subscriber Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship to Client
Secondary Insurance Company Name
ID Number
Group Number
Insurance Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurancy Company Phone
Subscriber Name
First Last
Employer of Subscriber
Subscriber Date of Birth
Date Format: MM slash DD slash YYYY
Subscriber Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship to Client
No Insurance?
- No insurance and I have NOT applied
- No, and I HAVE applied
Date of application for insurance
Date Format: MM slash DD slash YYYY
Release of Information
I Agree to the following
I authorize Northland Counseling Center, Inc. to release information to my insurance company regarding my treatment and I permit a facsimile or photographic reproduction of this athorization in place of the original. This could include my Social Security number, diagnosis, prognosis, dates of treatment, narrative notes, and types treatment. This is for the purpose of validating claims submitted to stated insurance carrier. I also athorize stated insurance carrier to make payments to Northland Counseling Center, Inc. for all insurance benefit to which I or my dependents are entitled for services received. I understand that this consent will terminate one year from the signature date unless I choose to revoke it earlier.
Statement of Understanding
I agree to the following
I understand that I am responsible for the charges in full if I do not maintain coverage for which I am eligible or fail to provide insurance information and/or income verification (if interested in fee reduction).

I recognize that Northland Counseling Center, Inc. cannot gauruntee payment of charges by any particular insurance carrier. If I have questions regarding coverage, I will contact my insurance company.

In the event Northland Counseling Center, Inc. has been unable to collect payment from me for servces within a reasonable period of time, the Center then reserves the right to turn the account over for colletion of my bill. A 15% processing fee will be added to any account sent collection.

I affirm that the information on rever is accurate I am aware of my financial responsibilities and agree to the payment terms. I authorize the release of information to my insurance carrier(s). If my address, phone number, financial status, or insurance coverage changes, I will notifiy Northland Counseling Center, Inc., and an update of the agreement may be renegotiated.
Telehealth Consent*
I agree to the following
PURPOSE: The purpose of this form is to inform you of the availability of telemedicine services offered by Northland Counseling Center, Inc. Telemedicine involves the use of electronic communications to enable office visits from a site other than Northland Counseling Center, Inc.

‘Telemedicine’ means using electronic systems to allow communication between a client and a provider who are in different locations. Any service that Northland Counseling Center, Inc. offers may be provided via telemedicine.

CONFIDENTIALITY: Northland Counseling Center, Inc. utilizes Zoom, a third-party web-based video-conferencing vendor, to facilitate telemedicine services. Protected health information (PHI) will be transmitted via Zoom during telemedicine visits. Zoom incorporates networking software security protocols to protect the confidentiality of patient identification and will include measures to safeguard PHI and ensure the integrity against intentional or unintentional corruption.

Reasonable and appropriate efforts have been made to illuminate any confidentiality risks associated with the telemedicine consultation and all existing confidentiality protections under Federal and Minnesota State Law applied information disclosed while utilizing telemedicine services.

RIGHTS: As a part of the admission process, Northland Counseling Center, Inc. staff will request your consent to participate in telemedicine services in connection with services provided by Northland Counseling Center, Inc. and all satellite offices associated within.

You may withhold or withdraw consent to telemedicine services at any time without affecting your right to future services with Northland Counseling Center, Inc. or risk the loss or withdrawal of any program benefits to which you would otherwise be entitled. Your request to withdraw consent must be made in writing and submitted to Northland Counseling Center, Inc. staff.

RISKS, CONSEQUENCES and BENEFITS: In rare cases, the information transmitted may be inadequate quality or, if the equipment is not working, there could be delays in evaluation and treatment. In these cases, the visit maybe rescheduled or your provider will discuss face-to-face visit needs. You or your provider may discontinue the telehealth visit if the connections are not adequate for the situation. Very rarely, security protocols could fail, causing a breach of confidentiality. Northland Counseling Center, Inc. has implemented appropriate security measures to mitigate against this rare situation.
Uploaded Documents
Please upload a copy of the front and back of your insurance card. Please upload a copy of any gaurdianship/power of attorney paperwork from the courts.
File
File
Name of Person filling out form:
Thank you
Please take time to fill out Adult Health Questionnaire; GAIN-SS, PHQ-9 and WHODAS forms for your intake to be complete.

Adult Registration Form

Power of Attorney or Gaurdian Information

Insurance

Uploaded Documents

Thank you

Location & Hours

Latest News

Complete Continuum of Care

Adult Registration Form

Adult Registration Form

Power of Attorney or Gaurdian Information

Insurance

Uploaded Documents

Thank you

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Location & Hours

Latest News

Complete Continuum of Care