Forms and Insurance

FORMS
A set of forms will be provided at your first visit. If you prefer, you can print them out here and complete them ahead of time to bring with you. Most forms only require your signature. If you have any questions about these forms, call our office or bring them up with your therapist at your first appointment.

Informed Consent to Participate in Telemedicine Services

Client Information Form - adult

Client Information Form - children under 18

Financial Information Form - adult

Financial Information Form - children under 18

Client's Bill of Rights (signature only)

Financial Responsibility Form (signature only)

Payment Policy

Appointment Cancellation Policy and Payment Policy Consent (signature only)

Consent to Use and Disclose Health Information (signature only)

Informed Consent Agreement (signature only)

Client Acknowledgement Form (signature only)

Referral for Patient Treatment (signature only)

Client Questionnaire

If you would like a copy of our Notice of Privacy Practices, please click here.

HRSA Service Statement

Northland Counseling Service Statement

Sliding Fee Scale Poverty Guidelines

Sliding Fee Scale Application

FEES
Northland Counseling Services accepts many insurance plans, which frequently cover part or all of the cost of therapy. We also accept Medicare, Badger Care, and Medical Assistance, client payment options are also available.  Northland Counseling Services will offer a Sliding Fee Discount Program to all who are unable to pay for their services. Northland Counseling Services will base program eligibility on a person's ability to pay and will not discriminate on the basis of age, gender, race, sexual orientation, creed, religion, disabilty, or national origin.  The Federal Poverty Guildlines are used in creating and annually updating the sliding fee schedule (SFS) to determine eligibility. 

If you will be using your insurance plan, please bring your insurance card to your first appointment. We ask that co-pays or payments toward your deductible be made at the time of service.  Northland Counseling Services does not accept credit card or debit card payments at this time.

If you have any questions about insurance or billing, please contact our billing manager at 715-634-0222.