Child/Minor Intake Forms
1320 South Frontage Road, Suite 200 Hastings, MN 55033-2481 651-500-0905 651-437-2616 fax LutzTherapy.com
Child/Minor Client Information
Client Name: Client Date of Birth:
Client Phone Number:
Name of Parent/Guardian Completing this Form: Relationship to Client: Parent or Guardian Phone:
Second Parent/Guardian Name: Relationship to Client: Parent or Guardian Phone:
Phone Type: Appointment Reminder Texts ok?
Parent or Guardian 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/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 child’s rights as a client of Tom Lutz and Associates and the limits of confidentiality. I also understand my financial responsibilities as the parent/guardian of a client.
I have been informed of the risks, including but not limited to my confidentiality in treatment, of transmitting my child’s protected health information by unsecured means. My signature means that I have read and understand the above mentioned documents.
I attest to my knowledge of and agreement with the policies above.
Click Here to Review the Communication Policy
I consent to allow my child’s 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 for my child to receive treatment. I also understand I may terminate this consent at any time.
I acknowledge understanding of and agreement with the communication policy.
Telehealth Informed Consent
I, hereby provide consent for my child, , born on , to engage in telehealth with Tom Lutz and Associates LLC as a part of the therapy process and 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 that my child has the following rights with respect to telehealth:
I acknowledge understanding of and agreement with the telehealth policy.
Authorization to Disclose Protected Health Information to Primary Care Physician
Communication between Behavioral Health Providers and your child’s Primary Care Physician (PCP) is important to ensure that your child receives comprehensive and quality healthcare. This form allows your Behavioral Health Provider to share Protected Health Information with your child’s 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 my child’s 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 child’s primary care physician:
Primary Care Provider Contact Details (if applicable):
Consent for the Treatment of a Minor
Please indicate the current custody situation of the minor child below:
Acknowledgement & Consent
I understand that at least one parent/guardian must accompany the minor child to their first appointment and any subsequent appointments as deemed necessary by the therapist.
I acknowledge understanding of this policy and provide consent for the treatment of my minor child.
My signature below codifies my agreement with and acknowledgment of the policies contained herein.
Leave this empty:
If you have questions about the contents of this document, you can email the document owner.
Document Name: Child/Minor Intake Forms
Agree & Sign