Our electronic intake and consent forms utilize email communication for transmission of your information.

Email and text messaging, while efficient, are relatively insecure.

Please be informed that these methods, in the typical form, are not confidential means of communication. While we use encryption to secure the contents of emails sent between our webservers and your inbox, there is still a chance these communications, which may contain confidential information, could be intercepted.

The kind of parties that may intercept these messages include, but are not limited to:

Third parties on the Internet such as server administrators and others who monitor Internet traffic.

We offer electronic documentation for convenience and to remove barriers to care. It is not a requirement to receive services. If you'd prefer not to utilize electronic documentation, please do not complete this form, and call us at 651-500-0905 to discuss alternative methods for completing this paperwork.

By proceeding past this page, and clicking the box below, you are acknowledging the risks explained above and agreeing to utilize our electronic forms and email communication.

People in your home or other environments who can access your phone, computer, or other devices that you use to read and write messages.
Your employer, if you use work email to communicate with any employee of Tom Lutz and Associates.

Consent(Required)

I consent to electronic communication.

I have read the Client Policy, HIPAA Information Form and Communications Policy. I understand my rights as a client of Tom Lutz and Associates and the limits of confidentiality. I also understand my financial responsibilities as a client.

I have been informed of the risks, including but not limited to my confidentiality in treatment, of transmitting my protected health information by unsecured means. My signature means that I have read and understand the above mentioned documents.

HIPAA Policy(Required)

I have read and understand the Client Policy, HIPAA Information Form and Communications Policy.

I hereby assign payment of insurance benefits to include major medical benefits to Tom Lutz and Associates and to release any medical information deemed necessary to secure payment. I understand that if I have insurance coverage, but do not give the necessary information needed for billing purposes, I will be responsible for 100% of the charges I incur.

Assignment of Benefits(Required)

I have read and agree to the above statement regarding the assignment of benefits

Today’s Date *(Required)

Client Name *(Required)

First Last

Client’s Date of Birth *(Required)

Client Phone *(Required)

Ok with receiving text reminders? *

yes

no

Client eMail *(Required)

Ok with receiving email reminders? *

yes

no

Emergency Contact 1 Name*(Required)

First Last

Emergency Contact 1 Phone*(Required)

Emergency Contact 1 Relationship*(Required)

Emergency Contact 2 Name*(Required)

First Last

Emergency Contact 2 Phone*(Required)

Emergency Contact 2 Relationship*(Required)

Reffered 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? *(Required)

What are the goals you’d like to accomplish in therapy? *(Required)

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?*(Required)

Yes, I agree to the coordination and to the release of my diagnosis to my physician

Enter a Different Date

To sign the form electronically, please use your mouse or touchscreen to draw your signature in the box below.(Required)

By clicking the “Submit” button below, you agree that your electronic signature is valid and binding as if you had signed a paper document with a pen.

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Untitled

First Choice

Second Choice

Third Choice

Adult Intake Form

Therapy Goals

Authorization to Disclose Information to Primary Care Physician