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:  

Today’s Date:    

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:

Client’s Family:

What problems have caused you to seek therapy?

What are the goals you’d like to accomplish in therapy?

Referred by:

 

 

1320 South Frontage Road, Suite 200  Hastings, MN  55033-2481
651-500-0905   651-437-2616 fax    LutzTherapy.com

Policy Acknowledgement & Consent for Treatment

 

Client Name:   
Client Date of Birth:  
 

Client Policy, Consent for Treatment & HIPAA Rights/Policy

Click Here to Review the Client Policy & Consent for Treatment

Click Here to Review the HIPAA Policy

I 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.

 

Communication Policy

Click Here to Review the Communication Policy

I 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.

 

1320 South Frontage Road, Suite 200  Hastings, MN  55033-2481
651-500-0905   651-437-2616 fax    LutzTherapy.com

Telehealth Informed Consent

 

Client Name:   
Client Date of Birth:  

 

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:

  1. I have the right to withhold or remove consent at any time without affecting my right to future care or treatment, nor endangering the loss or withdrawal of any program benefits to which I would otherwise be eligible.
  2. The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information released by me during the course of my sessions is generally confidential. There are both mandatory and permissive exceptions to confidentiality including but not limited to reporting child and vulnerable adult abuse, expressed imminent harm to oneself or others, or as a part of legal proceedings where information is requested by a court of law. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written consent. I agree not to retain any recording of nor image from a telehealth session.
  3. I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the therapist, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons. Tom Lutz and Associates LLC utilizes secure, encrypted audio/video transmission software to deliver telehealth.   In addition, I understand that telehealth-based services and care may not be as complete and in-person services. I understand that if my therapist believes I would be bettered served by other interventions I will be referred to a mental health professional who can provide those services in my area. I also understand that there are potential risks and benefits associated with any form of mental health treatment, and that despite my efforts and efforts of my therapist, my condition may not improve, or may have the potential to get worse.
  4. I understand I have the right to access my personal information and copies of case notes. I have read and understand the information provided above. I have discussed these points with my therapist, and all of my questions regarding the above matters have been answered to my approval.
  5. By signing this document, I agree that certain situations including emergencies and crises are inappropriate for audio/video/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 911 or go to the nearest hospital or crisis facility. By signing this document, I understand that emergency situation may include thoughts about hurting or harming myself or others, having uncontrolled psychotic symptoms, if I am in a life threating or emergency situation, and/or if I am abusing drugs or alcohol and are not safe. By signing this document, I acknowledge I have been told that if I feel suicidal, I am to call 911, local county crisis agencies or the National Suicide Hotline at 1-800-784-2433.
  6. Payment for Telehealth Services: Tom Lutz and Associates LLC will bill insurance for telehealth services when these services have been determined to be covered by an individual’s insurance plan. In the event that insurance does not cover telehealth or the individual wishes to pay out-of-pocket please speak with your therapist regarding setting up a self-pay structure.
 

1320 South Frontage Road, Suite 200  Hastings, MN  55033-2481
651-500-0905   651-437-2616 fax    LutzTherapy.com

Authorization to Disclose Protected Health
Information to Primary Care Physician

 

Client Name:   
Client Date of Birth:  

 

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:

Tom Lutz and Associates https://lutztherapy.com
Signature Certificate
Document name: Adult Intake Forms
Unique Document ID: fb0facb7121e52d60b7babb914d28798d117b87d
Timestamp Audit
April 13, 2020 11:25 am CDTAdult Intake Forms Uploaded by Anne Hewitt - admin@lutztherapy.com IP 75.72.214.61
April 16, 2020 3:10 pm CDT Document owner justin@askdavinci.com has handed over this document to admin@lutztherapy.com 2020-04-16 15:10:55 - 174.53.135.153