Intake Forms

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  • Dawna Gutzmann, MD & Associates

    Offices in Skokie & Chicago Loop

    Mailing Address: 5225 Old Orchard Road, Suite 36, Skokie, IL 60077
    Phone: (312) 488-9599
    E-mail: info@DGutzmannMD
    Website: www.DGutzmannMD.com


  • Date Format: YYYY slash MM slash DD
  • INFORMED CONSENT TO TREATMENT AND/OR EVALUATION

  • I hereby authorize the psychiatric/psychological treatment and/or evaluation of myself (or the above named child) by Dr. Gutzmann (or her associate). I have discussed stated goals of psychological treatment and/or evaluation and I understand that I have the right to ask for information regarding diagnosis, goals for treatment, and estimated length of treatment.

    I have read the Patient’s Rights & Responsibilities document and understand my rights & responsibilities as a patient with Dawna Gutzmann, MD & Associates.

    I have read the Privacy Practices document and the Limits of Confidentiality document and I understand these policies and legal requirements regarding confidentiality.

    I understand that personal notes taken by Dr. Gutzmann (or her associate) represent the personal work product of my therapist and as such, remain her/his sole property. I understand and agree that Dr. Gutzmann (or her associate) may properly retain such documents in my file according to professional standards. She/he is not required to release personal notes about my care, since these represent work product, and are not part of the formal psychological record. Copies of actual records and/or typewritten reports about my care can be sent out if I provide proper written authorization, and this will be done according to professional standards. There may be a fee for preparing and sending records.

    In the event of a life-threatening emergency, I can page Dawna Gutzmann, MD by calling (847) 610-0393 and leaving a message. Pages without messages will not be answered. I also understand that if a life is in imminent danger, I will not wait for Dawna Gutzmann, MD to respond. I will immediately call 911 or go to the nearest emergency room for assistance.

    I have read the Financial Policies document and understand the policies of Dawna Gutzmann, MD & Associates.

    I have read the Cancellation Policy document and understand the policies of Dawna Gutzmann, MD & Associates regarding cancellation of appointments. I understand that the cancellation fee must be paid before any further services are rendered, unless other arrangements are made. This fee will be charged directly to the client’s credit card, if available.

    I understand that this agreement becomes part of my psychological record, which is accessible to the parties at will, but to no other person without written consent.

  • (or Legal Guardian)
  • Date Format: YYYY slash MM slash DD