Adult Intake Form (Otter Creek)

Adult Intake Form
Personal Information
Referred To: *Please note - Psychiatry may be limited, if available.*

TherapyPsychiatry (Medication)Therapy & Psychiatry
Location:*

BurlingtonSouth BurlingtonShelburne
Legal Last Name:*
Legal First Name:*
Preferred Name and Pronouns:
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone:

Area CodePhone Number
Cell Phone:

Area CodePhone Number
Work Phone:

Area CodePhone Number
Ok for Message?

HomeWorkCell
E-mail:
Birth Date:*

MonthDayYear
Current age:*
Gender on record if using health insurance:
Referred By:
PCP:
Location:
To Make an Appointment, Contact:
Phone Number:

Area CodePhone Number
Current Medication:
Current Diagnosis (if applicable):
Reason For Referral (please be specific, as this will help us connect you with an appropriate provider): *
Availability (please list both days and times):*
Are you seeking telehealth or in person sessions?*

In personTelehealthNo preference
Do you have a preference regarding the gender of the provider?*

FemaleMaleNon-binaryNo prefrenece
Insurance/Billing Information
Insurance:*
Phone:
Policy ID:*
Group Number:*
Employer:*
Secondary Insurance:
Subscriber:*
SSN:
Enter the message as it's shown*
Is there anything else that you would like us to know?
Should be Empty:

Adult Intake Form