BHSI
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    • Brooklyn Center
    • Eagan
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Forms

If you are going to attend your first appointment at BHSI, you can print these forms ahead of time and complete them at home.
General forms 
  • BHSI Client Rights and Responsibilities
  • Telehealth Consent Form
  • Authorization to Release Information 
  • BHSI Statement of Privacy Practices
  • Tips on Refilling Your Prescriptions
  • E-Mail Authorization Form

Adult Intake Forms
  • Adult Re-Open Form (use this instead of the Adult Intake Form if you have been to BHSI in the past) 
  • Adult Intake form
  • Telehealth Consent Form
  • Insurance form 
  • Insurance Payment Order
  • Treatment Agreement
  • Primary Care release of information
  • Medica Wellness Assessment ( If you have Medica Insurance) 

Adolescent Intake Forms
  • Adolescent Intake Form
  • Telehealth Consent Form
  • Insurance form
  • Insurance Payment Order
  • Treatment Agreement
  • Primary Care release of information
  • Medica Wellness Assessment (If you have Medica Insurance)

Child Intake Forms
  • Child Intake Form
  • Telehealth Consent Form
  • Insurance form
  • Insurance Payment Order
  • Treatment Agreement
  • Primary Care release of information
  • Medica Wellness Assessment (If you have Medica Insurance)

Other Forms
  • Vanderbilt Assessment Scales
  • BHSI Specialty Injection Clinic Form
  • Injection Clinic Referral Instructions
New patient appointments:
651-662-0800
Screening tool
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