Patient Forms


New Patient Packet

Information about about our practice and policies as well as registration and consent forms. Please read and complete prior to your first visit.

Medical History

Questionnaire about medical history and overall health. Complete and sign where indicated.

Disclosure Authorization

Authorization to disclose protected health information. Required to send information to an outside provider or agency.

Information Request Authorization

Authorization to request protected health information. Required to solicit information from an outside provider or agency.

Provider Forms


Referral Procedures

Instructions for referring patients to BBMC.

Intake Form

For initial and sub-specialty referrals.

Treatment Authorization Request

Psychiatrist request for additional treatment. (For use with Santé IPA patients.)

Treatment Authorization Request

Therapist request for additional treatment. (For use with Santé IPA patients.)