Vortex Psychiatry- Workers Compensation

Welcome to my practice. I want to begin by acknowledging that being involved in a workers’ compensation case often comes with physical, emotional, and practical challenges. It’s completely normal to have questions or concerns during this process, and I am here to support your mental and emotional well-being throughout your recovery.

This packet includes important information to help us get started, including forms required for your initial psychiatric evaluation and treatment. These documents allow me to understand your background, current symptoms, and the circumstances of your work-related injury, so that I can provide you with the most effective care tailored to your needs.

Please complete all forms to the best of your ability before our first appointment. If you need assistance filling them out, don’t hesitate to contact my office.

All of our sessions, including this initial evaluation, are confidential and focused on helping you heal and regain your sense of stability and functionality. My goal is to work collaboratively with you, your medical team, and your workers’ compensation representative to support your treatment and recovery process.

Thank you for allowing me to be part of your care. I look forward to working with you.

Warm regards,

Said A. Ibrahimi, M.D., QME

Vortex Psychiatry

Patient First Name

Patient Last Name

Patient Date Of Birth:

Patient Email

Patient Address (Street, City, Zip Code)

Best Contact Phone Number

Other contact phone number

Leave message on voicemail

Yes No

Leave message with person(s)

Yes No

Person name to leave message and relationship to Patient:

Reason for Appointment and Date of Injury:

Workers Compensation Adjustor's Information: Phone Number and Email Address

Workers Compensation

Attorney Name

Attorney Phone Number

Attorney Email

Patient's Social Security Number

Office Policies and HIPAA Policy Acknowledgement

Our HIPAA policy is posted on our website: www.VortexPsychiatry.com Please be sure to read it.
The office staff is available to answer your call from 8 AM to 4 PM. Monday to Thursday. Our phone lines are closed on Friday's. We are available by email at vortexpsychiatry@outlook.com

Patient (please sign):

Contract for Controlled Substances

Controlled substance medications (i.e., benzodiazepines and stimulants) are very useful. However, they have potential for misuse and therefore are controlled by local, state, and federal authorities. Because my provider is prescribing such medications for me, I agree to the following conditions:

I am responsible for the controlled substance medications prescribed to me. If my prescriptions and/or medication are misplaced, stolen, or if “I run out early”, I understand that this medication will not be replaced regardless of the circumstances.
I will not request or accept controlled substance medication from any other physician or individual while I am receiving such medication from Vortex Psychiatry. Besides being illegal to do so, it may endanger my health. I understand that if I violate any of the above conditions, my prescriptions for controlled medications may be terminated immediately. If the violation involves the concomitant use of nonprescription or illicit (illegal) drugs, I may also be reported to other physicians, pharmacies, medical facilities, and the appropriate authorities.
I am aware that all requests for prescriptions must be in writing during business hours. a) I am responsible for taking the medication in the dose prescribed and for keeping track of the amount remaining. Renewals are based upon keeping scheduled appointments. b) Refills will not be made as an “emergency”. No controlled medications can be ordered when the office is closed. I understand the importance of following my treatment plan as directed by my physician and agree to keep my scheduled appointments.
I understand that if I violate this controlled substance contract due to non-compliance of medical directions, such as: failure in taking medications as prescribed, utilizing other illicit drugs, obtaining similar medications from others, or abuse of controlled medications, I may be subject to dismissal from this practice.
I understand that the main treatment goal is to improve my ability to function. I am being given potent medication to help me reach that goal and agree to help myself by following better health habits. I understand that using illicit drugs will negatively impact my progress. Continued use of illegal or illicit substances after warning can be cause for termination of medical care and reporting to authorities.

I have read this contract and fully understand its content and the consequences of violating this contract. By signing below, I accept the above treatment agreement.

Patient Signature:

Date:

No Show Policy:

Our policy is as follows:

We charge for all changes and cancellation of appointments with less than 1 business-day notice. There are no exceptions for this (including sickness, work travel, etc.) This is a typical policy for psychiatric office where a considerable time is set aside with no double booking. Should you need to inform us of your cancellation, during or after business hours, you can notify Vortex Psychiatry via email at: vortexpsychiatry@outlook.com or by phone: (925) 648-2650. We understand there are unforeseen events that may occur.
Fees are as follows for no call- no show- less than 24 hours' notice to cancel or reschedule your appointment.

After the 4th occurrence potential discharge of care from Vortex Psychiatry, per Dr. Ibrahimi's discretion.

Medication Refill Request Policy:

Before you request a refill request, please read:
We suggest keeping a 7-day supply of your medication in a separate bottle to avoid last-minute requests. All refill requests can take up to a MINIMUM of 3 business days to be received and viewed. They are typically filled within 3-5 business days (Monday – Thursday only) Please allow this much time for unforeseen issues. Please make your balance payment and schedule your follow up appointment prior to refill request to avoid further delays. We do not offer rush refill request.

Before a refill request is sent please ensure:

Your scheduled follow up appointment has been pre-scheduled. Refill requests are viewed and processed Monday Through Thursday only. All refill requests must be submitted through the webisites link. We do not accept refill requests over the telephone.
- We ask that you please make all requests for medication to this link, and do not go through your pharmacy to request medications. Often, the requests from the pharmacy do not go through and can cause delays in getting your medication.
Should you need an appointment contact our office Monday – Thursday 9 am -4 pm Vortex Psychiatry at 925-648-2650 You can also email us at vortexpsychiatry@outlook.com Our phone lines are closed on Fridays.
Not having an appointment will delay and hinder your ability to get your medication. Refill requests will be denied if you do not have an upcoming appointment/balanced paid in full.
Please make sure you are being seen regularly and do not miss any appointments. We will try our best to accommodate your appointment day and time of choice.
- If it is extremely urgent you have not exceeded your time between visits, your physician may prescribe a 7day to 15-day supply, their discretion.

Patient Signature:

Date

*Contact information of a person completing this form if not a patient

Name

Best contact phone:

Email:

Relationship to a patient

Have you seen other specialists for these problems/symptoms? (Approximate Dates)

Your Primary Care Physician:

Provider Name

Provider Phone:

Other Physicians and Therapists currently involved in your care

Provider Name

Specialty

Provider Phone

Provider Name

Specialty

Provider Phone

WORKERS' COMPENSATION CLAIM INFORMATION

Date of Injury

Description of Injury/Incident

Employer Name & Contact information

Street Adress, City, State, Zip Code , Phone Number, Fax Number, Email Address

Workers' Comp Insurance Carrier Name

Workers' Comp Insurance Carrier Phone Number & Email Address

Claim Number

Patient's Social Security Number

Attorney Name (if applicable)

Attorney Phone Number and Email Address (if applicable)

Financial Agreement and Assignment of Benefits

Financial Agreement and Assignment of Benefits Clarifies that workers' compensation is responsible for payment Informs the patient of their responsibilities if the claim is denied.

How would you rate your general health?

Excellent

Good

Fair

Not so good

Very bad

Do you have serious or chronic medical conditions, accidents, or injuries, including head injuries?

Yes No

Medications:

Please list all current medications, including vitamins and supplements

Have you had allergic reaction to any medication?

Yes No

What medications and extent of reaction

Recently, did you have unexplained?

Weight Loss Weight Gain

Recently, did you have unexplained?

Big change in appetite Increase or decrease

Big change in sleep pattern (briefly describe)

Big change in alertness and energy during the day (briefly explain)

History of medical and psychiatric hospitalizations

Medical and psychiatric hospitalizations

MEDICAL HISTORY:

Please check all that applies

Do you wear hearing aid?

Yes No

Do you wear glasses?

Yes No

Date of last menstrual period

Are you right or left-handed?

Right Left

Additional Medical Information

Health Habits

Alcohol and Other Drug use:

Do you drink, smoke, or use other (non-prescribed and non-OTC) drugs?

If yes, please answer the following questions.

Other (please specify)

What are your drink(s)/drug of choice?

Alcohol Other Drugs

How much do you drink or use per day/week?

Alcohol Other Drugs

Do you feel you have problems with alcohol or drugs?

Alcohol Other Drugs

Have you ever had a DUI or other drug related problems?

Alcohol Other Drugs

Has your drinking and/or drug use ever caused problems in the family, work, or in in your relationship(s)?

Alcohol Other Drugs

Previous treatment programs (dates and locations if possible)

LEGAL HISTORY:

(use additional space if needed)

Have you ever had any legal difficulties/problems or previous imprisonment?

Yes No

If yes, please describe

Is this evaluation part of the worker’s compensation proceedings?

Yes No

If yes, please describe

ADULT RATING SCALE

Major concerns (check all that apply):

Attention

Relationships

Professional

Health

Memory and thinking

Other (please specify)

Please rate these behaviors: 0 – Never (None) 1 – Sometimes (Mild) 2 – Often/Always (Severe)

(circle the most appropriate number)

Block I

Can't start a task

0 1 2

Hard to stay focused, easily distracted

0 1 2

Poor attention to details, careless mistakes

0 1 2

Forgetful, losing things

0 1 2

Poor planning, procrastination

0 1 2

Daydreaming

0 1 2

Leaving work unfinished

0 1 2

Impulsive decisions

0 1 2

Interrupting conversations

0 1 2

Acting before thinking

0 1 2

Fidgeting, shaking legs

0 1 2

Talking excessively

0 1 2

Moving constantly, changing positions

0 1 2

Hard to stay seated

0 1 2

Liking sameness, routine

0 1 2

Rigid and stubborn

0 1 2

Transitions are difficult

0 1 2

Perfectionist, works slow

0 1 2

Concerns about order and neatness

0 1 2

Block II

Gets into heated arguments

0 1 2

Losing temper, getting angry

0 1 2

Feelings are hurt, gets easily frustrated

0 1 2

Going through uncontrollable rages

0 1 2

Conflicts with authorities

0 1 2

Problems with the law

0 1 2

Arrests, DUI (details in few words)

0 1 2

Smoking cigarettes

0 1 2

Excessive drinking

0 1 2

Other drugs (legal and illegal), details

Block III

Nervous habits or tics

0 1 2

(describe)

Obsessive, intrusive thoughts or images

0 1 2

Compulsive behaviors

0 1 2

Storing things, not able to discard them

0 1 2

Excessive superstitions

0 1 2

Block IV

Worrying excessively about everything

0 1 2

Feeling tense, keyed up

0 1 2

Unable to stop worrying

0 1 2

Self-conscious , feelings easily hurt

0 1 2

Easily embarrassed, sensitive to criticism

0 1 2

Panic attacks

0 1 2

Panic attacks

0 1 2

Excessive fears (crowd, heights, etc.)

0 1 2

Nervous stomach, headaches

0 1 2

Family history of anxiety, panic, and social phobia

0 1 2

Excessive tiredness and daytime sleepiness

0 1 2

Always tired, hard to stay alert

0 1 2

Block V

Unhappy most of the day, most days

0 1 2

Crying

0 1 2

Thoughts of dying

0 1 2

Feeling guilty, being too hard on self

0 1 2

Feels things will never get better

0 1 2

Not enjoying anything anymore

0 1 2

Major changes in sleep and appetite

0 1 2

Feeling worthless, inferior (e.g. I am stupid)

0 1 2

Feeling that be better off dead

0 1 2

Thoughts of suicide

0 1 2

Feeling giddy, witty and funny

0 1 2

Mood changes quickly, drastically

0 1 2

Episodes of being talkative, pressure to talk

0 1 2

Periods of extreme energy alternating with periods of excessive tiredness and calm

0 1 2

Acting recklessly

0 1 2

Thinking more about romance and sex

0 1 2

Family history of depression or bipolar disorder

0 1 2

Block VI

Feeling indifferent, not caring

0 1 2

Loosing interest in thinks that liked before

0 1 2

Feeling drained of energy

0 1 2

Not seeing friends, mostly alone

0 1 2

Sleeps too much, always tired

0 1 2

Block VII

Sleep is disturbed, interrupted

0 1 2

Hard time falling asleep

0 1 2

Sleepwalking, -talking, night terrors

0 1 2

Block VIII

Hearing what others can't hear

0 1 2

Feeling others are out to get you

0 1 2

Strange, bizarre, intrusive thoughts

0 1 2

Being suspicious

0 1 2

Block IX

Change in appetite

Up Down

Weight

Loss or Gain

Recent

Vision Loss or Hearing loss

Recent change in health (describe)

Additional Comments:

Person(s) helping with the questionnaire:

Message to our patients about Arbitration

The attached contract is an arbitration agreement. By signing this agreement, we are agreeing that any dispute arising out of the medical services you receive is to be resolved in binding arbitration rather than a suit in court. Lawsuits are something that no one anticipates, and everyone hopes to avoid. We believe that the method of resolving disputes by arbitration is one of the fairest systems for both healthcare providers and their courts. Arbitration agreements between patients and physicians have long been recognized and approved by the State of California. By signing this agreement, yon are changing the place where your claim will be presented. You still can call witnesses and present evidence. Each party selects an arbitrator (party arbitrators), arbitrator. These three arbitrators hear the case. This agreement generally helps to limit the legal costs for both the patients and physicians. This is because the time it takes to conduct an arbitration hearing is far less than for a jury trial. Further, both parties are spared some of the rigors of a trial and the publicity which may accompany judicial proceeding.

Our goal, of course, is to provide medical care in such a way as to avoid any such dispute. We are all caring doctors and do our utmost to be responsive. We know that most problems begin with communication. Therefore, if you have any questions about your care, please ask us.

Date

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