Our Location

579 N. First Bank Dr.
Suite 150
Palatine, IL  60067

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Therapy Services

Child, Adolescent & Adult General Mental Health Services

General Behavioral Medicine Services

Women’s Behavioral Medicine Services

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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.

Dr. Kukla’s HIPAA registration PDF form 2018

 

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.

Dr. Kukla’s Release of Information 2018 PDF Form

 

Teletherapy/Video Conferencing/Phone Sessions:

Please download this PDF for Dr. Kukla’s Consent for Telemental Health Services form.

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