Northland Counseling Center

Committed to Recovery

Health Questionnaire (HQ) Ages 0-10

Thank you for choosing Northland Counseling Center! Please fill out the form below and once completed please make sure to also fill out Minor Registration Form, SDQ Parent Form & Authorization to treat a Minor. Once completed an intake staff will contacting you.

Age 0-10 Health Questionnaire Intake

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

  • School

  • Medical

  • Date Format: MM slash DD slash YYYY

  • Substance Use

  • Mental Health

  • If you do not receive a call from a staff within 2 days of submitting your paperwork please contact your local Northland Counseling Center location to ensure they have received your paperwork. Please ensure you click submit.