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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.
   
           
 

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

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
Gary A. Keller
Marcy Milton
Aida Reed Luce
Marc D. Richter
Scott Ward

 

  
           


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149 Cherry Street, Burlington, VT 05401
Phone: 802-863-2495 • Fax: 802-865-0534