© 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.
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).
Our clinic is committed to providing care to our community members regardless of ability to pay. If you meet certain income requirements you may be entitled to a discounted fee to see one of our providers.
Please see our income requirements here: NCBM Sliding Scale Requirements
If you would like to apply for the sliding scale program please complete this application and return it to one of our staff: NCBM Sliding Scale Application
© 2024 North Country Behavioral Medicine. All Rights Reserved.
