To Schedule An Appointment
Eastbrook Office Park
12720 West North Ave
Bldg B - Suite 200
Brookfield, WI 53005
The Hale Richlen Center for Psychiatry
Forms & Releases
PANDAS/PANS New Patient Form
For new patients, please complete the initial PANDAS/PANS Questionnaire and Autoimmune Family History. It can be submitted by either faxing it to our office at 262-785-1555 or submitting it through our website here when finished. Someone will be in contact with you within 3-5 business days.
New Patient PANDAS/PANS Assesment - Click to Open and Download or Print.
Autoimmune Family History-Click to Open
and Download or Print
Release of Information Form
For the Release of Information form, either print the form, fill it out and fax it back to our office at 262-785-1555 or download the form, fill it out, and then submit it through our website here.
Release of Information Form - Click to Open and Download or Print.
Completing Forms Online
To complete the forms online, they can be downloaded and completed in Adobe Acrobat. Alternatively, they can be uploaded, completed, and saved via PDFescape, a website that is completely free and requires absolutely no personal information.
All completed documents can be easily uploaded here.