Client Forms

•  Treatment Plan Consent

•  Authorization For Use and Disclosure of Protected Health Information
This document serves as both a Release of Information and a Medical Records request.

•  Release of Information


Substance Use Disorder Forms

Intake Paperwork

Vulnerable Adult Disclosure (signature required)
DAANES Notification of Data Collection (signature required)
Please read:
  •  Program Abuse Prevention Plan
  •  STD Information
  •  Hepatitis Information
       »  Hepatitis A
       »  Hepatitis B
       »  Hepatitis C
  •  HIV / AIDS Information
  •  Tuberculosis Information
  •  Opioid Information
  •  Testing Centers
Acknowledgment of Receipt of Information (signature required)


Comprehensive Assessment Forms

These forms will be reviewed during your initial appointment with your clinician. 

1. Substance Use Programs
2. Outpatient Risks and Benefits of Substance Use Treatment
4. Recovery Strategies
5. Transfers, Discharges, and Service Termination
6. Serenity Prayer

603 Bruce Street, Crookston, MN 56716
Phone (Non-Crisis): 218.281.3940 | Toll-free: 1.800.418.7326

© Northwestern Mental Health Center 2019 | Privacy of Health Information