Child & Adolescent Intake Form
Personal Information
Referred To: *Please note - Psychiatry may be limited, if available.
*
Therapy
and/or Psychiatry
Location
*
Burlington
South Burlington
Winooski
Shelburne
Legal Last Name
*
Legal First Name
*
Preferred Name and Pronouns:
School
Grade
Pediatrician
Parents/ Guardians
Married
Separated
Divorced
Unmarried
Legal Custody
Physical Custody
Mother
Mother
Natural
Adoptive
Foster
Step
Father
Parent 2
Natural
Adoptive
Foster
Step
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
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Poland
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Qatar
Republic of the Congo
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eSwatini
Sweden
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Tonga
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Vatican City
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Western Sahara
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Other
Country
Home Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Ok for Message?
Home
Work
Cell
E-mail
Birth Date
*
Please select a month
January
February
March
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June
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September
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Month
Please select a day
1
2
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31
Day
Please select a year
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2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
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1969
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1956
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1954
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1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Current age:
Gender on record if using health insurance:
Referred By:
PCP:
Location
To Make an Appointment Contact
Phone Number
-
Area Code
Phone 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 person
Telehealth
Hybrid
No preference
Do you have a preference of a male, female or non-binary provider?
*
Male
Female
Non-binary
No preference
What is your availability? Please list both days and times.
*
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