Child/Minor Mental Health Screening


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

Child/Minor Mental Health Screening

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. 

Leave this empty:

Tom Lutz and Associates https://lutztherapy.com
Signature Certificate
Document name: Child/Minor Mental Health Screening
Unique Document ID: 82f565cd4b1a3c1f0974a8edbaec6ee74dd3bfad
Timestamp Audit
April 15, 2020 10:28 pm CDTChild/Minor Mental Health Screening Uploaded by Anne Hewitt - admin@lutztherapy.com IP 174.53.135.153
April 16, 2020 3:08 pm CDT Document owner justin@askdavinci.com has handed over this document to admin@lutztherapy.com 2020-04-16 15:08:11 - 174.53.135.153