Thank you for choosing Northland Counseling Center. This form needs to be filled out by the parent/guardian.
If you have a custody agreement or documentation of legal guardianship please upload the document below or email or fax it to:
- Aitkin, Grand Rapids, Hibbing Locations: 218-327-8997
- International Falls Location: 218-283-3386
Once complete please be sure to fill out the other forms needed for intake Minor Registration, Ages 11-17 Health Questionnaire (HQ), GAIN-SS , SDQ-Parent Form, SDQ-Teen Form, GAD 7, Provider Supervision form & PHQ-A; once complete, intake staff will be contacting you.