Northern Woods Wellness LLC

Northern Woods Wellness LLC Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

What sex is on your insurance policy?

For insurance verification

State

Select the state you live in

Reason for care

What is the reason for seeking care?

Anxiety Behavioral issues Couples or family therapy Depression Grief Personality disorders Professional Coaching Substance use Trauma Other

What kind of care is being sought?

Therapy Professional coaching Court-mandated services (We are not able to provide this) Medication management (We are not able to provide this)

What mental health concerns or treatment have occurred in the past?

If you are requesting professional coaching services and not therapy, you may select "None of these apply".

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Billing & Payment

Payment method

How do you prefer to pay?

Insurance details: Company name, HMO name, and plan name

If you are requesting professional coaching services, these are self-pay only and you can enter "N/A" in this section and skip the insurance card upload.

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

Full Address (Required for all clients)

Limited to 600 characters

Client Preferences

Preferred Appointment Times: Each provider has a different specialty & schedule. Not all providers are available at all of these times.

Morning (9am-12pm) Afternoon (12pm - 5pm) Evening (5pm - 7pm)

Preferred modality

Is there anything that the provider needs to know?

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.