Networks Treatment Inquiry Form
If you are looking to see a therapist at Networks, completing this secure form is the first step and will help us connect you with the right provider. If you would prefer to complete this form by phone, please call (802) 863-2495.
Client/ Patient Name
*
First Name
Last Name
Referral Source
Self if not referred by another provider.
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Email
example@example.com
How can we leave or send you a message?
*
Phone
Text
Email
How would you prefer we contact you?
Phone
Email
Primary Phone Number
*
-
Area Code
Phone Number
Primary Phone Type
*
Home
Work
Cell
Secondary Phone Number
-
Area Code
Phone Number
Secondary Phone Type
Home
Work
Cell
OK to leave phone message or text?
*
Yes
No
OK to send an email?
*
Yes
No
Social Security Number
Date of Birth
*
Age
*
Gender
*
Place Of Employment
*
Parent/ Guardian Name (if under 18)
Leave blank if not applicable.
Legal Guardian?
Yes
No
Parent/ Guardian Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Phone Number
-
Area Code
Phone Number
Current Medications
Leave blank if none.
Prescriber Name and Phone Number
Primary Care Provider Name
Primary Care Provider Phone Number
How will you be paying for services?
*
Insurance
Private Pay
Primary Insurance
*
Name of insurance company.
Primary Insurance ID
*
Primary Insurance Policy Holder Name, DOB, and Relationship to Client (if different)
Secondary Insurance
Name of company. Leave blank if none.
Secondary Insurance ID
Secondary Insurance Policy Holder Name, DOB, and Relationship to Client (if different)
Emergency Contact Name
*
Emergency Contact Phone
*
Emergency Contact Relationship
*
Emergency Contact Email
Preferred Day/ Time for Appointments
Type of Therapy Requested
*
Individual
Couple
Family
Specific provider requested?
Reason(s) For Seeking Therapy At This Time
*
Submit
Should be Empty: