Adult Intake Forms
1320 South Frontage Road, Suite 200 Hastings, MN 55033-2481 651-500-0905 651-437-2616 fax LutzTherapy.com
Adult Client Information
Client Name: Client Date of Birth:
Client Phone Number:
Phone Type: Appointment Reminder Texts ok?
Client eMail Address: Appointment Reminder eMails ok?
Emergency Contact 1 Name: EC1 Phone Number: EC1 Relationship:
Emergency Contact 2 Name: EC2 Phone Number: EC2 Relationship:
What problems have caused you to seek therapy?
What are the goals you'd like to accomplish in therapy?
Policy Acknowledgement & Consent for Treatment
Client Name: Client Date of Birth:
Client Policy, Consent for Treatment & HIPAA Rights/PolicyClick Here to Review the Client Policy & Consent for TreatmentClick Here to Review the HIPAA PolicyI have read the Client Policy, HIPAA Information Form and Communications Policy. I understand my rights as a client of Tom Lutz and Associates and the limits of confidentiality. I also understand my financial responsibilities as a client.I have been informed of the risks, including but not limited to my confidentiality in treatment, of transmitting my protected health information by unsecured means. My signature means that I have read and understand the above mentioned documents.
I acknowledge understanding of and agreement with the policies above.
Communication PolicyClick Here to Review the Communication PolicyI consent to allow my therapist at Tom Lutz and Associates to use unsecured email and mobile phone text messaging to transmit to me the following protected health information:
Information related to the scheduling of meetings or other appointments.
Information related to billing and payment.
I understand that I am not required to sign this agreement in order to receive treatment. I also understand I may terminate this consent at any time.
I attest to my knowledge of and agreement with the policies above.
Telehealth Informed Consent
I, , born on , consent to engaging in telehealth with Tom Lutz and Associates LLC as a part of the therapy process and my treatment goals. I understand that telehealth psychotherapy may include mental health evaluation, assessment, consultation, treatment planning, and therapy. Telehealth will occur primarily through interactive audio, video, and/or other audio/video communications.
I understand I have the following rights with respect to telehealth:
I attest to my knowledge of and agreement with the telehealth policy.
Authorization to Disclose Protected Health Information to Primary Care Physician
Communication between Behavioral Health Providers and your Primary Care Physician (PCP) is important to ensure that you receive comprehensive and quality healthcare. This form allows your Behavioral Health Provider to share Protected Health Information with your PCP. This information will not be released without your signed authorization. This Protected Health Information may include diagnosis, treatment plan, verbal communication and psychological testing/evaluations per your permission.
I, the undersigned, understand that I may revoke this consent at any time. I cannot be required to sign this form as a condition of treatment. I have a right to a copy of the signed authorization. If I make a request to end this authorization, it will not include information that has already been used or disclosed based on my previous permission. I have read and understand the information and give my authorization.
My preference regarding notification of my primary care physician:
Primary Care Provider Contact Details (if applicable):
My signature below codifies my agreement with and acknowledgment of the policies contained herein.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Adult Intake Forms
Agree & Sign