Adult Mental Health Screening


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

Adult Mental Health Screening

Electronic Communication Consent Acknowledgment:    

Client Name:  
Client Date of Birth:

 

I attest that I have completed the following electronic screening tools on this date:  CAGE, Patient Health Questionnaire (PHQ-9) & Generalized Anxiety Disorder (GAD-7). The answers to these screening tools were provided by me and represent my state of mind at the time the screening tools were administered. 

Leave this empty:

Tom Lutz and Associates https://lutztherapy.com
Signature Certificate
Document name: Adult Mental Health Screening
Unique Document ID: 323ebcd1f9b446db381502f36c8903739c866b0a
Timestamp Audit
April 15, 2020 8:17 pm CDTAdult Mental Health Screening Uploaded by Anne Hewitt - admin@lutztherapy.com IP 174.53.135.153
April 16, 2020 3:09 pm CDT Document owner justin@askdavinci.com has handed over this document to admin@lutztherapy.com 2020-04-16 15:09:35 - 174.53.135.153