Pediatrics at Newton Wellesley | Downloads

Behavioral health documents

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

To submit:

• Reply to the original MyChart message you received.
• Click blue button that says “attach image or video.”
• 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 pnw.secure@pedinw.org and also send a MyChart message letting us know that you submitted the forms through email.

Initial intake paperwork

• FORM A. Behavioral Health Intake Form- Online version OR Behavioral Health Intake Form- Print out version
• FORM B. Vanderbilt – Parent
• FORM C. Vanderbilt – Teacher
• FORM D. SCARED – Child
• FORM E. SCARED – Parent

Followup paperwork

• FORM F. Follow-Up Vanderbilt – Parent
• FORM G. Follow-up Vanderbilt – Teacher
• Over 18 Years Of Age Authorization To Release Information
• Behavioral Health Authorization for Disclosure of Clinical Information