Initial Contact Form Initial Contact Summary First Letter of Last Name*Name* First MI Last Date of Birth* Date Format: MM slash DD slash YYYY Mailing Address* Street Address City State / Province / Region ZIP / Postal Code Home PhoneMessage Ok By checking this box, I acknowledge it is okay to leave a message on my home phone.Cell PhoneMessage OK By checking this box, I acknowledge it is okay to leave a message on my cell phoneText By checking this box, I consent to recieving text messages.Email Consent to receive emails By checking this box, I consent to receiving emails from Northland Counseling Center, Inc.Emails will consist of upcoming appointment appointment reminders or messages to coordinate appointment dates/times. No personal information will be shared.Parent, Spouse or Emergency Contact First Last Person Retaining Legal Custody, If Not a Parent First Last Address of Person who has Legal Custody Street Address City State / Province / Region ZIP / Postal Code Phone # of Person who has Legal CustodyPlease tell us what brings you here today.*Who were you referred by?*Primary Care Physician and Clinic Name*Do you currently have a Mental Health Therapist or Psychiatrist, if yes, Who?*Insurance Name*Insurance ID #*Insurance Group #Policy Holder Name*Policy Holder Date of Birth*Relation to Client*Policy Holder Employer NamePhysicians, Hospitals, Mental Health Providers seen in the past 3 yearsProvider Name, Facility Name, City, StatePhoneThis field is for validation purposes and should be left unchanged.
