Behavioral Health Document Downloads

Please complete the form(s) requested by your provider and submit them via MyChart.

To submit:

  1. Reply to the original MyChart message you received.
  2. Click blue button that says “Attach image or video” 
  3. Upload all document you want to send in your reply

If you are unable to upload the forms via MyChart please email the completed forms to BHteam@pedinw.org and also send a MyChart message letting us know that you submitted the forms through email.

FORM A. Behavioral Health Intake Form- Online version            OR        Behavioral Health Intake Form- Print out version