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Northland Counseling Center
Committed to Recovery
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Client Portal Proxy Form Ages 0 – 11
Client Portal Proxy Form Ages 12-17
Client Portal Proxy Form for ages 18 and older
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Online Intake Ages 11-17
Minor Registration Ages 11-17
Ages 11-17 Health Questionnaire (HQ)
Authorization to treat a Minor – Ages 11 -17
11-17 Screeners (Child Does)
Ages 11-17 SDQ – Parent Form
Provider Supervision Form
Release of Information – Agencies & Providers
Online Intake ages 0-10
Minor Registration Ages 0-10
Health Questionnaire (HQ) Ages 0-10
Authorize to Treat a Minor ages 0-10
SDQ Parent Form Ages 4-10
Child ACEs and Related Life Events Screener (Caregiver Report)
Provider Supervision Form
Release of Information – Agencies & Providers
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