Minges Brook Counseling Service
9 Heritage Oak Lane, Suite 9
Battle Creek, Michigan 49015
24 Hr. Phone 269-979-4800
Directions to Minges Brook Counseling Service
Mary Peacock, LMSW, ACSW
Licensed Master Social Worker

Personal Information Sheet
Notice of Privacy Practices
Privacy Practices Receipt
Personal Checklist
Fee Schedule

Owen Bolton, LMSW, ACSW
Licensed Clinical Social Worker

Introduction to Clinician
Client Information Form *
Statement of Understanding for Couples Therapy
DASS 21 Questions *
Client Insurance Form *
Release of Authorization for Health Insurance *
Notice of Privacy Practice
Privacy Practices Receipt *
Policies, Services, & Fees *
* Indicates this form is required to be filled out by all new Clients and brought to the first visit.