Priscilla Brinkman, LCSW, FT
Priscilla Brinkman, LCSW, FT

Patient Forms

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.

 

*Informed Consent

 

*Client Information

 

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



All Forms
This PDF contains all of the forms listed below in a single document.
All_Forms.pdf
Adobe Acrobat document [101.1 KB]
Informed Consent
Informed_Consent.pdf
Adobe Acrobat document [63.0 KB]
Client Information
Client Information - PB.pdf
Adobe Acrobat document [54.6 KB]
Notice of Privacy Practices
Notice_Of_Privacy_Practices.pdf
Adobe Acrobat document [38.8 KB]
Insurance Checklist
Insurance Checklist - PB.pdf
Adobe Acrobat document [39.2 KB]
Assignment of Benefits
Assignment of Benefits - PB.pdf
Adobe Acrobat document [28.1 KB]
Credit Card Agreement
Credit_Card_Agreement.pdf
Adobe Acrobat document [29.1 KB]

Note: You will need Adobe(r) Reader(r) to view PDF files. If you do not have it, you can download it for free.

Where to Find Priscilla:

Priscilla Brinkman, LCSW, FT

825 W State St.

Suite 118

Geneva, IL 60134 

 

Phone: 630-471-2117

Email Priscilla

 

Available By Appointment

Patient Forms

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.

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