Child & Adolescent Intake Form (Otter Creek)

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

Therapyand/or Psychiatry
Location*

BurlingtonSouth BurlingtonWinooskiShelburne
Legal Last Name*
Legal First Name*
Preferred Name and Pronouns:
School
Grade
Pediatrician
Parents/ Guardians

MarriedSeparatedDivorcedUnmarried
Legal Custody
Physical Custody
Mother
Mother

NaturalAdoptiveFosterStep
Father
Parent 2

NaturalAdoptiveFosterStep
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 match you with an appropriate provider)
Insurance/Billing Information
Insurance
Phone
Policy ID
Group Number
Employer
Secondary Insurance
Subscriber
SSN
Do you have a preference of in person or telehealth sessions?*

In personTelehealthHybridNo preference
Do you have a preference of a male, female or non-binary provider?*

MaleFemaleNon-binaryNo preference
What is your availability? Please list both days and times. *
Enter the message as it's shown*
Should be Empty:

Child & Adolescent Intake Form