Intake Forms

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
Patient Name*
First Name Last Name
Date of Birth
YYYY slash MM slash DD
Legal Guardian
Address
Street Address Address Line 2 City State ZIP Code
Email*
Telephone #
Alternate Phone#
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.
Patient Signature
(or Legal Guardian)
Date
YYYY slash MM slash DD

Confidential Personal History
Name
First Last
Date
YYYY slash MM slash DD
Parent/Guardian (if under 18 years)
How did you hear about us?
Occupation
Do you enjoy your work?
What difficulties, if any, are you experiencing at work?
Describe any difficulties in your level of motivation:
Describe any difficulties in productivity & effectiveness:
How many brothers & sisters do you have?
Where are you in the birth order of your family of origin?
Describe the family “atmosphere” in which your were raised:
Are you married or in a romantic relationship?
If so, for how long?
How satisfied are you with your relationship currently?
Do you give & receive affection frequently?
Describe any change in your sexual life:
What type of contraception do you use?

Please list any children by first name & age

First Name	Age

Describe any difficulties you are currently having in your home life:
What is your educational background?
Describe any challenges with learning.
Does it seem to be as easy as ever to make decisions? If not, please describe:
What are your usual leisure pursuits, hobbies & keen interests?
Are you able to derive as much pleasure from them as usual lately?
How do you typically like to socialize (a few close friends, numerous friends, one on one, in groups, etc.)?
Have you had as much desire to socialize with friends and family as usual?
Do you have a close friend in whom you can confide?
Describe any social difficulties:
Describe any change in your attention to your appearance or hygiene:
Is your self-esteem/confidence as good as ever, better than ever or lower than usual lately?
What do you do to manage stress?
What are some of your greatest strengths?
What habits, if any, do you have that might hinder your success?
Do you organize your time effectively?
Do you have an adequate income for your needs?
What was your family’s religion, if any, when you were a child?
Do you have a spiritual practice?
Do you get strength from spiritual beliefs?
Describe any major life stressors you have experienced in the past 2 – 3 years.
Describe three behaviors that concern you the most:
How long have these problems persisted?
If no change occurs, what are you most concerned will happen?

Release of Information
I request and authorize

Dawna Gutzmann, MD 5225 Old Orchard Rd., Suite 36 Skokie, IL 60077

To release the information specified to the healthcare professional, agency, hospital or medical center listed below:
Name (Your Therapist)
First Last
Address
Street Address Address Line 2 City State ZIP Code
Telephone number
Fax number
Information or communication requested: Diagnosis, treatment recommendations, progress
Regarding
Name
First Last
Date of Birth
YYYY slash MM slash DD
Purpose of release of information: Coordination of care

The statues that govern this authorization include but are not limited to: Mental Health and Developmental Disabilities Confidentiality Act (740 ILCS 110), 735 ILCS 5/7 2001 (inspection and copying of hospital records and any relevant confidentiality code of any state, and the Employee Personnel Act, 820 ILCS 40/0.01.

I understand that I have a right to copy and inspect the information being disclosed. I have the right to revoke this authorization in writing, at any time by sending such written notification to my provider’s office. Written revocation is effective upon receipt. However, my revocation will not be effective to the extent that my provider has taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

I understand that my provider may not condition psychological services upon my signing an authorization unless the psychological services are provided to me for the purpose of creating health information for a third party. It has been explained to me that if I refuse to consent to this Release of Information specified above, the following are the consequences:
Authorization: I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and complete to the best of my knowledge. I understand that I may have a copy of this form at any time that I choose to request it. The authorization will automatically expire in one year from the date of signature or, if I prefer, on the date specified here:
Printed name
Signature
Date
YYYY slash MM slash DD

Release of Information
I request and authorize

Dawna Gutzmann, MD 5225 Old Orchard Rd., Suite 36 Skokie, IL 60077

To release the information specified to the healthcare professional, agency, hospital or medical center listed below:
Name of your primary care physician
First Last
Address
Street Address Address Line 2 City State ZIP Code
Telephone number
Fax number
Information or communication requested: Diagnosis, treatment recommendations, progress

Purpose of release of information: Coordination of care

The statues that govern this authorization include, but are not limited to: Mental Health and Developmental Disabilities Confidentiality Act (740 ILCS 110), 735 ILCS 5/7 2001 (inspection and copying of hospital records and any relevant confidentiality code of any state, and the Employee Personnel Act, 820 ILCS 40/0.01.

I understand that I have a right to copy and inspect the information being disclosed. I have the right to revoke this authorization in writing, at any time by sending such written notification to my provider’s office. Written revocation is effective upon receipt. However, my revocation will not be effective to the extent that my provider has taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

I understand that my provider may not condition psychological services upon my signing an authorization unless the psychological services are provided to me for the purpose of creating health information for a third party. It has been explained to me that if I refuse to consent to this Release of Information specified above, the following are the consequences:
Authorization: I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and complete to the best of my knowledge. I understand that I may have a copy of this form at any time that I choose to request it. The authorization will automatically expire in one year from the date of signature or, if I prefer, on the date specified here:
Printed name
Signature
Date
YYYY slash MM slash DD
Comments
This field is for validation purposes and should be left unchanged.

Step 1 of 6

Dawna Gutzmann, MD & Associates

INFORMED CONSENT TO TREATMENT AND/OR EVALUATION

Confidential Personal History

Health

Family Health History

Do you have a family history of :

Release of Information

Release of Information

Are you ready to take the next step and get the support that you deserve?

Skokie:

Chicago:

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