Several forms need to be completed before your first appointment. All forms are available at the office, however filling them out in advance saves time. Please print and complete the following documents. Forms required are noted by an asterisk. Please feel free to contact me if you have questions regarding any of the forms.
Notice of Privacy Practices: This is your copy of Notice of Privacy Practices
*Notice of Privacy Practices Acknowledgment
*Insurance Checklist: If you plan on using your insurance benefit, please use this form as a guide to contact your insurance company to confirm mental health benefits.
*Assignment of Benefits: Required if using insurance benefits
Credit card Agreement: If you wish to use a credit card for payment of services, please complete this form
Note: You will need Adobe(r) Reader(r) to view PDF files. If you do not have it, you can download it for free.
Priscilla Brinkman, LCSW, FT
825 W State St.
Geneva, IL 60134
New patient? Save time and reduce the amount of paperwork you have to fill out at your first visit. Priscilla provide several patient forms as PDF downloads on our site.