Mental Health Assessment, Evaluation, and Testing Forms

Please complete the Initial Contact Summary, Online Telemedicine and Release of Information along with the correct In-Take Packet for the age of the client.

Northland is now offering you the flexibility to submit most of  your forms online.  Once you have completed your forms, an In-Take Specialist will be contacting you.  You can also print the forms and mail them if you prefer.  If you would like to print and email the forms, please contact us at 218-283-3406.

Initial Contact Summary

Intake Packet Age 4-10

Intake Packet Age 11-17 

Intake Packet Adult

Release of Information

Notice of Privacy Practices

Diagnostic Assessment

During the initial meeting with a therapist, individuals seeking services at Northland Counseling Center’s International Falls office will be asked a series of questions about their strengths and resources, what brings them in for services, what goals or outcomes are sought, any history of emotional, psychological, behavioral, or medical problems that might be important, relevant family and social history, and so forth. From all of this information, the therapist will develop a comprehensive, Diagnostic Assessment report and Treatment Plan, including diagnosis, mutually agreed upon goals and recommendations for appropriate services. Once the individual returns to discuss the Treatment Plan with the therapist, agreed upon services will be started through Northland Counseling Center or referrals will be made to other agencies, as appropriate.

Testing and Evaluations

Some clients will require more extensive diagnostic services involving formal testing/evaluation. Our Licensed Psychologists are available to administer an array of testing and evaluation instruments designed to provide important information to the client, loved ones, and referral sources (including your primary therapist).

Examples of types of evaluation available through Northland Counseling Center’s International Falls office include:

  • ADD/ADHD Evaluations
  • Bariatric Pre-surgical Psychological Evaluations
    (Rou-En-Y or Lap-Band surgery)
  • Law Enforcement Applicant Evaluations
  • Dementia Screenings
  • Developmental and Intellectual Disabilities
  • Others

Examples of evaluation instruments administered at Northland Counseling Center’s International Falls office include:

  • Parent, teacher, and self-rating scales and computer testing for problems with attention or child’s emotions and behavior
  • Objective personality inventories (such as the MMPI) designed to help in diagnosing a broad range of problems that might affect relationships, employment and enjoyment of life
  • Intelligence and neuropsychological screening tests that can be helpful in identifying mental retardation, memory problems and other types of dementia (such as Alzheimer’s)
  • Mood and anxiety screening scales to help identify the presence and severity of depression and anxiety symptoms
  • Others

For information or to schedule an appointment for Assessment, Evaluation or Testing Services, contact our Receptionist at
218-283-3406 Ext. 0