Initial Contact Form Initial Contact Summary First Letter of Last Name* Name* First MI Last Date of Birth* 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 Name Physicians, Hospitals, Mental Health Providers seen in the past 3 yearsProvider Name, Facility Name, City, StateIf 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.CommentsThis field is for validation purposes and should be left unchanged.
