*Please contact a Northland Health Centers Team Member before completing the following forms, to ensure you are filling out the correct forms and including the correct necessary documentation. ​

Child/Adolescent Behavioral Health Forms:
 (All Forms must be completed by the parent/guardians except the PHQ-9 form.)

​Demographic/Intake Form

Informed Consent Telehealth Form

​Informed Consent Form

New Patient Child/Adolescent
​
PHQ-9(Ages 12 and Up)

Sliding Fee Scale Application 

Sliding Fee Scale Waiver

Patient Responsibility Notice

Release of Information
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​Please Email Sliding Fee Scale Application, Sliding Fee Scale Waiver, Release of Information, and Informed Consent completed forms to 
BH@northlandchc.org