© 2024 North Country Behavioral Medicine. All Rights Reserved.
Prior to becoming a patient at NCBM all potential patients will be required to complete the appropriate Intake Form(s). Below you will find links that will take you to our online intake forms. This process is fully HIPPA compliant and these forms will be sent to us via a secure portal. This is the preferred method of submitting intake forms to our clinic.
If you are having trouble completing the Online Forms, please use the links below the online forms to download or print our intake forms.
PLEASE COMPLETE THESE FORMS WITH AS MUCH DETAIL AS POSSIBLE.
FORMS MISSING DETAILS WILL RESULT IN DELAYS AND POSSIBLY NOT BEING TAKEN ON AS A PATIENT.
If you are having trouble completing the forms online, you can download and/or print Intake Form using these links:
If you are having trouble completing the forms online, you can download and/or print the TMS Intake Form using this link:
Forms completed online will be sent to the clinic directly using a HIPPA compliant process.
If forms are completed using the download/print option, then forms can be sent to us via fax at (802) 404-1492, mail at 441 Watertower Circle, Suite 200, Colchester, VT 05446, or via email at colchester@ncbm.com (not HIPPA compliant).
© 2024 North Country Behavioral Medicine. All Rights Reserved.
