Minor Registration Ages 0-10

When you have completed this form, please make sure you have also completed the Health Questionnaire (HQ) ages 0-10, SDQ Parent Form , Supervision Form & Authorization to treat a Minor. Once these forms are completed an intake staff will be contacting you.

Minor Registration Form Ages 0-10

Today's Date
MM slash DD slash YYYY
Email
Name
First Middle Last
Phone number
Location in which you would like your services?
- Grand Rapids
- Hibbing
- Aitkin
- International Falls
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Consent
I authorize Northland staff to contact me at the above address, by checking this box you agree to allow Northland staff to contact you.
Home Phone
Consent
I authorize Northland staff to contact me at the above home phone number, by checking this box you agree to allow Northland staff to contact you.
Work Phone
Consent
I authorize Northland staff to contact me at the above work phone number, by checking this box you agree to allow Northland staff to contact you.
Cell Phone
Consent
I authorize Northland staff to contact me at the above cell phone number, by checking this box you agree to allow Northland staff to contact you.
Birthdate
MM slash DD slash YYYY
Social Security Number
Sex
- Male
- Female
Client's Primary Physician
Minor Information
Mother's Name
Does mother reside with Client?
- Yes, Full-Time
- Yes, Part-Time
- No
Father's Name
Does father reside with Client?
- Yes, Full-Time
- Yes, Part-Time
- No
What type of legal custody does Mother have?
- Full legal Custody
- Physical Custody
- Joint Legal Custody
- Custody not yet determined
- Other, please explain below
If joint custody or none of the above, please list name, address and phone number of other party retaining custody:
What type of legal custody does Father have?
- Full legal Custody
- Physical Custody
- Joint Legal Custody
- Custody not yet determined
- Other, please explain below
If joint custody or none of the above, please list name, address and phone number of other party retaining custody:
(Northland is required to obtain consent to treat this minor from the above named person): If you are able to upload a copy, please feel free to do so here or one of our intake staff will be in contact with you.
Max. file size: 300 MB.
Insurance Information
Primary Insurance Company Name
Primary Insurance ID Number
Primary Insurance Group Number
Primary Insurance Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Primary Insurance Phone Number
Subscriber Name
First Middle Last
Subscriber Date of Birth
MM slash DD slash YYYY
Subscriber Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Relationship to client
Secondary Insurance Company Name
Secondary Insurance ID Number
Secondary Insurance Group Number
Secondary Insurance Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Secondary Insurance Phone Number
Subscriber Name
First Middle Last
Subscriber Date of Birth
MM slash DD slash YYYY
Subscriber Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Relationship to client
No Insurance
- No insurance and I have NOT applied
- No and I HAVE applied
Date of application for insurance
MM slash DD slash YYYY
Release of Information
By checking this box, you 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
By checking this box 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.
Telemedicine Consent*
By checking this box 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.
I, CLIENT (If able to ck box), acknowledge that all information is true and correct to the best of my knowledge
By checking this box, I acknowledge that the information is true and correct
I, PARENT/GAURDIAN, acknowledge that all information is true and correct to the best of my knowledge
By checking this box, I acknowledge that the information is true and correct
Uploaded Documents
Please upload a copy of the front and back of your insurance card. Please upload a copy of any court documents custody. If there are any issues, please wait on the documents and out intake staff will contact you on additional documents needed.
File
Max. file size: 300 MB.
File
Max. file size: 300 MB.
Name of person filling out form
First Last

Minor Registration Form Ages 0-10

Minor Information

Insurance Information

Uploaded Documents

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