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
Adult Intake Forms
Adolescent Intake Forms
Child Intake Forms
Injection Clinic Forms
- BHSI Client Rights and Responsibilities
- Informed Consent for Telehealth Services
- 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)
Injection Clinic Forms