Helpful Forms

If you're a new client, please complete the following forms and bring them to your first therapy session.

Luke Lukens LCSW

Patient Information

Date: ________________________

Name: ______________________________________

Street Address: ________________________________________________

City: __________________________ State: ______ Zip: ___________

Cell Phone: _________________________

Home Phone: _______________________

Work Phone: ________________________

Date of Birth: ________________________ Age: _______

SS#: _______________________________

Employer: __________________________

Email address: ____________________________________________

Emergency Contact Info

Name: _______________________________________

Relationship: __________________________________

Address: _____________________________________________________

Phone: _______________________________________________________

Insurance Information

Name of policy holder: ______________________________________

Date of Birth: _____________________________________

Relationship to patient: self, spouse, parent, partner, other

Insurance company: _________________________________________

Policy holder’s employer: ____________________________________

Required: A copy of your insurance card and drivers license

Reason for seeking therapy


Have you been in therapy before? _________________________________

Are you on any medication? _____________________________________

A. Luke Lukens LSCW Inc.

Psychotherapy Agreement
Welcome to my practice and thank you for your business. This document contains important information  about my professional services and business policies. Please read it carefully and jot down any questions  that you have so that we may discuss them at our next session. For further information about my experience and training please visit my web page at  You may also go to my web page to schedule appointments.

Services and Fees
Psychotherapy involves several different approaches that can be used to address the specific issues or 
challenges for which you are seeking treatment. There are numerous benefits to be gained from psychotherapy, but as with any form of treatment, there are also potential risks. Psychotherapy involves  discussing in depth many aspects of your life experiences in order to understand the current issues.  Experiences from the past may be addressed with the focus on how they impact the present. Therapy requires your active participation; the goals for your treatment will be discussed.

The duration of each session is 45 minutes. Once an appointment is scheduled you are responsible for payment unless you cancel 24 hours prior to the session. Missed appointment fees are $20 for the missed  session and $30 for subsequent missed appointments. The fee for the initial evaluation is $120.00. The fee for each subsequent session is $100.00; co-pays are payable at the time of the session.  And payment in full may be required if deductibles have not been met with your insurance. I accept Visa and Master card as well as cash and checks.

I accept I accept most major insurances: Medicare, Medicaid, as well as Medicaid CMO’s.   A complete list of insurance companies that are accepted can be found on my web page.  You may be required to contact your insurance company to determine benefits or if any pre-authorization  is required.

Confidentiality is one of the most important elements of psychotherapy. As your therapist I am legally 
bound and morally obligated, within certain legally defined limitations, to uphold and maintain your privacy and keep your personal information strictly confidential. None of your information will be 
revealed to any other person or agency without your written permission. However, there are specific circumstances that legally require me to reveal information obtained during psychotherapy. These circumstances include when there is a threat to yourself or others. Additionally any situation where 
there is a reason to be concerned about possible abuse or neglect of a child, elderly or handicapped 
person. You should also be aware that if you are using a third party reimbursement, I am required to 
provide the insurer with a clinical diagnosis and often a treatment plan or summary.
For clients under 18 years of age, please be aware that your parents have the right to receive general 
information regarding your treatment and may request a summary of how treatment is proceeding. I will 
discuss with you and your parent(s) what specific information will and will not be shared.

Limitation regarding litigation: Due to the nature of the therapeutic process and the fact that it often 
involves making a full disclosure with regard to many matters which may be of a confidential nature, it is
agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes,
injuries, lawsuits, etc) neither you nor attorney, or anyone else acting on your behalf will require testimony
in court or any other proceeding. Nor will disclosure of psychotherapeutic records be requested.

Contact information: Routine messages left during the business day will be returned as soon as possible.
I can be reached at 404-242-4772 or via email at [email protected] . In the event of an emergency and
I am unavailable, please call 911 or go to your nearest emergency room for evaluation.

Your signature below indicates that you have read and you understand the information in this
agreement and agree to abide by its terms during our professional relationship.



Parent/Guardian Signature:_______________________________

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:

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