INTAKE FORM

 

This completed intake form is needed for the first session.  

Please make sure to bring it with you - fully completed.

Feel free to make a front and back copy of your insurance card if you are using insurance. Or please bring your insurance card so that I may copy it when you arrive.  

If client is a minor in a split custody case, both custodial parties must sign the "Welcome To My Practice" and "Primary Care Physician Consent" sheets.

This Disclosure of Information form is also needed for the first session.

 

If client is a minor, please also complete the Child Intake Addendum Form.

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© 2023 by Marc D. Richter, PLLC. Proudly created by Marc

2 Church St., Suite 3G

Burlington, VT 05401
Marc@MarcRichter.org

Tel: (866) 429-2074
Fax: (802) 540-8199