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	Directions: Please download and complete the Intake (#1) and Privacy Practices Forms (#3) if you are an adult. Please also print the first page of the Disclosure of Information Form (to the right) for the therapist that you are meeting with. If the client is a child, please also download and complete that form (#2) as well.

	1. General Networks Intake Information Form Download Word Document \| PDF Version 2. Child Information Form Download Word Document \| PDF Version 3. Notice of Privacy Practices Download Word Document \| PDF Version 4. Demographics Sheet (Single Face Sheet) Download Word Document \| PDF Version ATTENTION! INSURED MEMBERS MANAGED BY MBC / MAGELLAN WILL ALSO NEED TO FILL OUT THE FORMS BELOW 1. Informed Consent For Treatment Form (Magellan) Download Word .doc \| PDF Version 2. Member's Rights & Responsibilities Statement (Magellan) Download Word .doc \| PDF Version 3. Primary Care Practicioner Form (Magellan) Download Word .doc \| PDF Version To schedule an appointment please call Network's general voicemail. (802) 863-2495 ext.9	Disclosure of Information Forms Rebecca Brooks Jason S. Frishman Charles D. Gottlieb Diane T. Gottlieb Pamela Gundlach Kristine Karge Marcy Milton Aida Reed Luce Marc D. Richter Scott Ward Shana Witkin

HOME \| THERAPISTS \| TYPES OF THERAPY & SERVICES \| ISSUES \| RESOURCES \| FORMS \| CONTACT US Copyright 2010- Networks Inc. 149 Cherry Street, Burlington, VT 05401 Phone: 802-863-2495 • Fax: 802-865-0534