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Directions: Please download and complete the Intake (#1) and Privacy Practices Forms (#3) if you are an adult.

If the client is a child, please also download and complete that form (#2) as well.
FORMS IN PDF MODE ARE CURRENTLY DISABLED BUT WILL BE BACK UP ON OUR SITE SOON!
  
         
 

1. General Networks Intake Information Form
Download Word .doc |

2. Child Information Form
Download Word .doc |

3. Notice of Privacy Practices
Download Word .doc |

ATTENTION! INSURED MEMBERS MANAGED BY MBC / MAGELLAN WILL ALSO NEED TO FILL OUT THE FORMS BELOW

1. Informed Consent For Treatment Form
Download Word .doc |

2. Member's Rights & Responsibilities Statement
Download Word .doc |

3. Primary Care Practicioner Form
Download Word .doc |

 

To schedule an appointment please call Network's general voicemail.

(802) 863-2495 ext.9

    
         


HOME | THERAPISTS | TYPES OF THERAPY & SERVICES | ISSUES | RESOURCES | FORMS | CONTACT US

Copyright 2008 Networks Inc.
149 Cherry Street, Burlington, VT 05401
Phone: 802-863-2495 • Fax: 802-865-0534