Request an Appt

If you would like to request an appointment with one of our providers please fill out the form below. Once the form is completed and Intake Coordinators will contact you. If you have never received services through Northland Counseling Center, Inc. please start by filling out the intake forms. This will assist our Intake Coordinators in scheduling your initial appointment. Thank you for choosing Northland Counseling Center, Inc!

Initial Contact Form

Initial Contact Summary

Name*
First MI Last
Date of Birth*
MM slash DD slash YYYY
Mailing Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone
Message Ok
By checking this box, I acknowledge it is okay to leave a message on my home phone.
Cell Phone
Message OK
By checking this box, I acknowledge it is okay to leave a message on my cell phone
Text
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 Custody
Please 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 Name
Physicians, Hospitals, Mental Health Providers seen in the past 3 years
Provider Name, Facility Name, City, State
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.
Comments
This field is for validation purposes and should be left unchanged.

Initial Contact Form

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