Behavioral Health Services (BHSI) Forms

Forms

If you are going to attend your first appointment at BHSI, you can send forms to us by mail, fax, or email.

Clinic addresses and fax numbers are listed at the bottom of this page.

To email forms:
1) Complete the online form(s) and then save each one to your device.
2) Click here to start an email to [email protected], then attach your forms and send.

General forms

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

_{BHSI Eagan
3460 Washington Dr, Suite 200
Eagan MN 55122

Fax: (651) 769-6249}

_{BHSI Brooklyn Center
6300 Shingle Creek Parkway,}
_{Suite 370
Brooklyn Center MN 55430
fax: (651) 769-6299}

_{BHSI Golden Valley
8441 Wayzata Blvd, Suite 140
Golden Valley, MN 55426

Fax: (651) 769-6349}

_{BHSI North St Paul
2497 7th Ave E, Suite 101
North St Paul, MN 55109

Fax: (651) 769-6449}

_{BHSI Shakopee
327 S. Marschall Rd, Suite 250
Shakopee, MN 55379
Fax: (651) 769-6549}