Patient documents

For your convenience, below you will find our patient paperwork. Please complete the appropriate document(s) and return them to lsyrstad@brookingsivycenter.org prior to your appointment. If you do not have email access, please return your paperwork to our office in person via curbside drop off or via US Mail at:

Brookings Behavioral Health & Wellness

211 4th St.      Brookings, SD 57006

Ph: (605) 697-2850      Fax: (605) 697-2874



Instructions to Complete Document(s) Electronically

  1. Select document you wish to complete; a new web browser will open displaying the PDF document.
  2. Download and Save the document to your computer. (not be able to complete document within web browser)
  3. Once saved to your computer; open the document and complete the appropriate blanks. 
  4. When the document is completed, make sure to save. (the document will not save automatically).
  5. Attach the completed document(s) to an email addressed to lsyrstad@brookingsivycenter.org.


If you have any questions or concerns, please do not hesitate to contact us.

New Patient Forms (pdf)

Download

Telehealth Agreement (pdf)

Download

Release of Information (pdf)

Download

Financial Eligibility FY21 (pdf)

Download

Teen Court Forms (pdf)

Download

referrals

If you are another office or facility and would like to refer your patient to our office, please fill out the form below. In order for our office to act on the referral we must have the requested forms attached. You will find the list of requested documents on the referral form. 


Thank you for your referral. We look forward to working with you and your patient. 

Referral Form (pdf)

Download

Frequently Asked Questions

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What insurances do you accept?

We accept several major insurances. We accept Medicare and Medicaid for our providers. We accept Medicaid for any of our staff (case managers and clinicians). No insurance - no problem.

What are the costs for services?

These costs displayed are a guideline. Please note that we provide services to everyone, regardless of their ability to pay. We accept most major insurances and offer a sliding scale fee based off of household size and income. Please contact our office for any questions or concerns you may have.

         Counseling Appointments

             Initial Appointment     $181.00 per hour

              Return Appointment  $162.00 per hour

        Medical Appointments

             Initial Appointment    $300.00 per hour

             Return Appointment  $150.00 per hour


How long do sessions last?

First sessions are typically 60 minutes long. Subsequent sessions may very depending on your treatment plan and availability. 

How frequently should I attend counseling?

Depending on your customized treatment plan, you may decide to meet weekly, biweekly, or monthly for 30-60 minutes on average. It may change throughout your treatment. We will help work with you and your schedule!

I work full-time, what are my options?

The first appointment with one of our staff members needs to be scheduled during our normal business hours 8am-5pm Monday through Friday but subsequent appointments can be coordinated with counselors availability. 

What is your privacy policy?

Our agency abides by HIPPA guidelines and policies. While filling out paperwork upon first session, a staff member will discuss our privacy policy with you and answer any specific questions you may have. Release of information forms are available for clients and may be revoked at any time.