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