Please select your provider below to load their professional disclosure. In order to begin working with your provider, you will need to review their professional disclosure packet. If you have questions, please reach out to your provider for more information.

Please Note: You may ignore the first page of the document as that information, and the signature, is included in this web form instead.

The packet above includes the following...

1. Professional qualifications of each provider
2. A list of actions that constitute unprofessional conduct according to Vermont statutes
3. The methods for making a consumer inquiry or filing a complaint with the Office of Professional Regulations
4. Notice of Mental Health Policies and Practices to Protect the Privacy of Your Health Information
5. The prescription policy for your provider if you will be working with a psychiatric or medical provider.

My signature acknowledges that I have been provided the professional qualifications of my provider, a listing of actions that constitute unprofessional conduct according to Vermont statutes, the methods for making a consumer inquiry or filing a complaint with the Office of Regulation, and if this disclosure is for a psychiatric or medical provider, the prescription policy for that provider

My signature below also acknowledges that I have received the “Notice of Mental Health Policies and Practices to Protect the Privacy of Your Health Information” from Networks, Inc. Any questions that I’ve had regarding this information have been asked and answered by my provider.