Our Location

Harris Bank Building
800 E. Northwest Highway
Suite 500
Palatine, IL 60074
Phone: (847) 701.4452
or (847) 701.4HLC
See Map

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New Client Forms

New clients are asked to print out a registration packet.  This packet includes two documents for you to read: the Client Agreement and the Notification of Privacy Practices. It also contains two forms for you to print out, complete, and bring to our first meeting: the Signature Form and the Client Information Form. Completing this paperwork in advance will allow us to focus immediately on how I can provide help when we first meet.

Click to Download New Client Forms

 

If there are any medical professionals you wish for Dr. Kukla to communicate with regarding your care.  Please print out a Release of Information Form and complete the top portion of the form along with the providers information you would like Dr. Kukla to exchange information with and bring to your appointment for further completion.

Click to Download Kukla Release of Information PDF Form

 

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