Uncategorized Archives - Tom Lutz and Associates

Gravity Forms Test Page

Standard / by Justin Scharr / April 15, 2020 / No Comments

Client Details
Today's Date*
Date Format: MM slash DD slash YYYY
Client Name*
First Last
Client Date of Birth*
Client Phone:*
Phone Type:*
- Mobile
- Home
- Work
Ok with receiving text message reminders?*
- Yes
- No
Client eMail:*
Ok with receiving email reminders?*
- Yes
- No
Emergency Contact 1 Name:*
First Last
At least one emergency contact is required.
Emergency Contact 1 Phone:*
Emergency Contact 1 Relationship:*
Emergency Contact 2 Name:
First Last
Emergency Contact 2 Phone:
Emergency Contact 2 Relationship:
Referred by:
Client's Family
Please enter a name, relationship and age for each member of your immediate family.
Therapy Goals
Why are you seeking therapy?*
What are the goals you'd like to accomplish in therapy?*
Authorization to Disclose 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.
Will you allow Lutz Therapy to communicate with and coordinate care with your primary care physician?*
- Yes, I agree to the coordination and to the release of my diagnosis to my physician.
- No, WAIVE NOTIFICATION of my PCP that I am seeking or receiving mental health services and I direct you NOT to notify my PCP
Primary Care Physician Name:
First Last
Primary Care Physician Address
Street Address Address Line 2 City State ZIP Code
Primary Care Physician Phone:
Primary Care Physician Fax:
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

Mental Health Services for All Ages

Gravity Forms Test Page

Client Details

Therapy Goals

Authorization to Disclose Information to Primary Care Physician

Archives

Meta