Child/Minor Mental Health Screening
1320 South Frontage Road, Suite 200 Hastings, MN 55033-2481 651-500-0905 651-437-2616 fax LutzTherapy.com
Electronic Communication Consent Acknowledgment:
Client Name: Client Date of Birth:
Name of Parent/Guardian Signing this Form:
I attest that I have completed the following electronic screening tools on this date: Adolescent CAGE, Patient Health Questionnaire (PHQ-9) & Generalized Anxiety Disorder (GAD-7). The answers to these screening tools were provided by me or my child and represent the state of mind at the time the screening tools were administered.
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Document Name: Child/Minor Mental Health Screening
Agree & Sign