1. health and fitness
2. therapy
3. physical therapy

Tom Lutz & Associates
651-500-0905
651-437-2616 fax
1320 South Frontage Road, Suite 200
Hastings, MN 55033
2000 Old West Main Street, Suite 300
Red Wing, MN 55066
WELCOME
We look forward to working with you. Please read the following notification. It summarizes practical
information about Tom Lutz & Associates and the therapeutic process in general. If you have any questions
or concerns about the information contained in this handout, please feel free to ask.
THERAPY: WHAT TO EXPECT
A therapist’s job is to assist clients in making healthy life choices. There are a number of factors that will
determine whether your therapeutic experience will be successful. In part, a successful outcome depends
on your sustained commitment, effort, flexibility, and courage. In your first session, your therapist will
discuss the issues that led you to contact us.
Your therapist will work with you to formulate and eventually achieve your therapeutic goals. You may find
that your goals change as you discover new insights and perspectives. Some clients experience therapy
as supportive. Others experience therapy as challenging and uncomfortable. Change is often difficult
and often requires a willingness to stretch. As you proceed, you may experience self-doubts, anxiety,
depression, anger, and conflict about some aspects of your life. This is normal.
When your therapeutic work is finished, you may realize that you’ve made unanticipated changes. For
example, you may have a different perception of your past, or you may participate in relationships differently
than expected. It is also quite likely that you will feel stronger or more settled in unexpected ways.
APPOINTMENT SCHEDULING
Each Tom Lutz & Associates therapist keeps his or her own appointment calendar and will try to
accommodate your schedule as much as possible. Alternative appointment times may be available. Consult
with your therapist to learn his or her office hours. We recommend that you schedule appointments well in
advance. A therapeutic session typically lasts 50 to 60 minutes.
CANCELATION POLICY
When your therapist schedules a block of time for you, other Tom Lutz & Associates clients will not be able
to use that time. Therefore, it is very important that you give the proper notice if you need to cancel.
1.) Tom Lutz and Associates requires 24 hours’ notice for cancelations.
2.) If you must cancel an appointment scheduled on a day after a holiday, a full business day’s notice
of the cancellation is required.
3.) If you fail to give your therapist 24 hours’ notice you will be charged a $70 fee. (This will be billed
as a “Late Cancellation/Failed Appointment Fee.”)
4.) Since emergencies and exceptions are inevitable, your therapist will have discretion regarding
exemptions.
*Please be aware that insurance carriers do not reimburse for missed appointments and often require
that such missed appointments be noted on your statement of charges.
PROFESSIONAL FEES
The Tom Lutz & Associates initial evaluation fee is $160. Each subsequent session fee is $150 per session.
(A sliding fee schedule may be available based upon income and insurance coverage, upon request.)
You are responsible for copayments and deductible payments. Deductibles and co-pays should be paid
at each session. If you do not use insurance, payment should be made at the beginning of each session
unless other arrangements have been made. Tom Lutz & Associates accepts credit cards, cash, or check.
You may request other services such as report writing, attendance at meetings or consultations with other
professionals, preparation of records or treatment summaries, copying of records, and legal testimony, and
so on. Your therapist may charge an hourly fee for these services. Since insurance often doesn’t cover
these ancillary services, you may be required to pay for them.
INSURANCE COVERAGE
Tom Lutz & Associates will bill your insurance carrier for you. If your insurance carrier refuses payment, you
are responsible for the payment of fees.
Please check with your insurance company to see whether you have mental health coverage and/or if Tom
Lutz & Associates is an “in-network” provider. If you require testing or special services, please check with
your insurance carrier if you are covered. Ultimately, it is up to you to insure that your insurance company
and specific policy cover you for the services you are requesting.
CONTACT
You may wish to contact your therapist or make appointments via phone or email. Some Tom Lutz &
Associates therapists use texting, as well. Your therapist will return your correspondence as soon as
possible.
EMERGENCIES
If you have an emergency of any kind, please use the emergency services available by dialing 911 on your
phone.
The following numbers are useful if you require urgent assistance:
Dakota County Crisis Center
(952) 891-7171
Washington County Crisis Center
(651) 777-5222.
THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
HIPAA requires that your therapist provide you with a Notice of Privacy Practices for use and disclosure
of Protected Health Information. The Notice (which accompanies this handout) explains HIPAA and its
application to your personal health information in greater detail. The law requires that your therapist obtain
your signature acknowledging that they have provided you with this information. It is important that you read
it carefully. Feel free to discuss any questions you have about procedures at any time. When you sign this
document, it will also represent an agreement between you and your therapist.
You may revoke this agreement at any time in writing. That revocation will be binding unless a.) your
therapist already has taken action; b.) there are obligations imposed on your therapist by your health insurer
in order to process or substantiate claims made under your policy; or c.) you have not satisfied any incurred
financial obligations. This agreement will be in effect for one year from the date of signing unless you
specifically request that it remain in effect for a shorter time.
LIMITS OF PRIVACY OF COMMUNICATION
The code of ethics of the American Psychological Association, other professional organizations, HIPAA, and
various laws of the State of Minnesota insure that conversations you have with your therapist will be held in
the strictest confidence. What you tell your therapist in session will be not disclosed to anyone without your
written authorization to do so. Your privacy is essential. However, there are exceptions to this rule and you
need to be aware of those exceptions before you disclose any information to your therapist:
1. On occasion, your therapist may consult with colleagues about your care. Your name will not be used
and your therapist will protect your identity. Your therapist will note all consultations in your clinical record.
2. If you file an insurance claim (see Insurance Coverage above) and ask to be reimbursed by your
insurance company for some portion of the costs of your therapy, then you will be giving your insurance
carrier the right to inquire about you. It is possible that your insurance carrier will direct your therapist
to send copies of clinical records regarding the content of your sessions. Failure to provide requested
information may result in your insurance carrier refusing to reimburse for services.
3. If you threaten to take your own life, your therapist will break confidentiality and call a family member,
the police, or other emergency personnel. In case of a threat to the life of a third party, your therapist has a
legal obligation to warn anyone you intend to harm.
4. If there is suspicion of abuse or neglect of a child or vulnerable adult, your therapist is mandated by law
to report that suspicion to the appropriate agency and to cooperate with any investigation.
5. If you disclose to your therapist unethical conduct by a medical or mental health professional, your
therapist is required by law to report that professional to the appropriate professional regulatory board.
6. If you sign a “Release of Information” form, your therapist can provide and receive from the identified
person(s) or agencies any and all information you have authorized.
7. If a court of law orders your therapist to release information, they must do so.
8. The organization which administers billing for Tom Lutz & Associates has access to the portion of your
information it needs to do its job. The contract between this organization and Tom Lutz & Associates meets
HIPAA regulations. Only the data necessary for billing will be released accordingly. Your session data will
remain confidential.
9. If your account is severely delinquent, Tom Lutz & Associates may obtain reimbursement through small
claims court or a collection agency.
10. If your insurance company and/or HMO audits Tom Lutz & Associates, reviewers may have access to
your file.
11. If you file a malpractice suit against your therapist, your therapist at Tom Lutz & Associates will be
permitted by the courts to reveal information about your therapy.
12. In the event of your death, information may be released to next of kin or to the coroner/medical
examiner investigating the cause of death.
13. If you file a worker’s compensation claim, your therapist must, upon appropriate request, disclose
information related to the claim to appropriate individuals, which may include your employer, the insurer, or
the Department of Labor and Industry.
If any of the above circumstances arise, your therapist will make every effort to discuss them with you fully
before taking action. Your therapist will also limit disclosure to what is necessary; often a summary or
report. As you might suspect, laws governing these issues are quite complex. While your therapist is happy
to discuss these issues with you, legal consultation is recommended if you need specific advice.
PROFESSIONAL RECORDS
Pursuant to HIPAA, Tom Lutz & Associates keeps Protected Health Information about you in a professional
file. This file includes information about reasons you sought therapy and/or evaluation, a description of
ways in which your problem impacts your life, your diagnosis, the goals we set for treatment, your progress
toward those goals, your medical and social history, your treatment history, any past treatment records
that your therapist receives from other providers, reports of any professional consultations, your billing
records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except
in unusual circumstances that involve danger to yourself and others, you may examine and/or receive a
copy of your Clinical Record, if you request it in writing. Because these are professional records, they can
be misinterpreted and/or upsetting to untrained readers. For this reason, it is recommend that you initially
review them in the presence of your therapist or have them forwarded to another mental health professional
so you can discuss the contents. If your therapist refuses your request for access to your records, you have
a right of review, which will be discussed with you upon your request.
PATIENT RIGHTS
HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures
of protected health information (see attached Notice). Your therapist is willing to discuss any of these rights
with you. Additionally:
- you have the right to be treated with dignity and respect at all times;
- you have the right to know about your therapist’s qualifications, including their training, credentials
and professional experience;
- you have the right to be informed in language you understand of your therapist’s assessment of your
difficulties, their recommendations for treatment, treatment alternatives and expected length of
treatment;
- you have the right to be informed of the purpose of and risks involved in any intervention your
therapist suggests;
- you have the right to specific, transparent information about fees, financial policies and billing
procedures of Tom Lutz and Associates;
- you have the right to request a referral, and to require your therapist to release information they
have gathered during your work together to other qualified professionals.
PATIENT RESPONSIBILITIES
- you are responsible for playing an active role in your treatment, including defining goals, understanding
and following your treatment plan, doing homework agreed upon between sessions, and providing input
into the direction and pace of our work;
- you are responsible for keeping your appointments and notifying your therapist as soon as possible
should you need to cancel an appointment;
- you are responsible for understanding your fees and paying what you owe for services;
- during your work with your therapist, you are responsible for notifying them of any changes in your
employment, insurance or financial circumstances so that if paying for services becomes a hardship, it
can be dealt with as soon as possible.
TREATMENT OF MINORS
Specific laws address confidentiality for minors (under age 18). In Minnesota, the custodial parent/legal
guardian has access to mental health records except when the minor is married, legally emancipated, or
has borne a child. Other exceptions include situations in which information in the records concerns venereal
disease, chemical dependency, or pregnancy, and related conditions.
A minor may request that data be withheld from parents/guardians. This request must be made in writing,
including the reason for withholding the information. If your therapist determines that the information would
be detrimental to the physical or mental health of the minor, or is likely to cause the minor to harm him or
herself or another, the therapist can withhold that data.
Parents are often understandably curious about their children’s sessions. However, it is important to
acknowledge that young people need to develop trust in their therapist and need some degree of privacy.
We ask that parents of minors in therapy at Tom Lutz and Associates respect this principle. Of course, your
therapist will bring to your attention matters that their professional judgment indicates are important for you
to know, and they will keep you informed about your child’s progress.
COMPLAINTS
If you have questions or concerns about you and your therapist working together, you are encouraged
to talk with your therapist about them. You have the right to seek outside consultation with other
professionals, and we support you in getting other opinions about your problems and/or what you are
experiencing in your relationship with your therapist.
If you have a complaint about your treatment at Tom Lutz & Associates and you do not believe you can
resolve that issue with your therapist directly, you may file a complaint with the Minnesota Board of
Psychology (612-617-2230), the Minnesota Psychological Association Ethics Committee (call MPA at 651203-7249), the Board of Social Work (612-617-2100), the Board of Marriage and Family Therapy (612617-2220), the Board of Behavioral Health and Therapy (612-617-2178), or the Minnesota Department of
Health (651-201- 5000).
COMPLETION OF THERAPY
You will be the one to make the ultimate decision about how long you remain in therapy. Your therapist
will consult with you about that decision. Your therapist is a resource for you. It is your right to terminate
therapy when you decide it is in your best interest. We encourage you to discuss the decision to end therapy
openly with your therapist.
Your therapist looks forward to working with you. We hope that work will be meaningful and helpful.