Child Package

In preparation for your first visit with Said A. Ibrahimi, M.D., Vortex Psychiatry, we will need some information.

Once we have verified your insurance benefits, a member of our staff will contact you as soon as possible to schedule your appointment. Please complete the information below.

Patient First Name

Patient Last Name

Patient Date Of Birth:

Patient Address (Street, City, Zip Code)

Guardian/Parent Best 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:

Parent/Guardian First Name & Last Name

Parent/Guardian (Complete address, if differs from above)

If MINOR: Does the patient live with both parents?

If not, is there a custody order?

Parent/Guardian Email

Parent/Guardian Occupation:

Student Unemployed Employed

Reason for Appointment:

Who were you referred by?

Insurance Provider (if applicable):

Insurance Name

Insurance Subscriber or ID Number

Insurance group number

You have an appointment with one of our doctors.

If you need to cancel this appointment, please give us 24 hours in advance notice. Canceling with less notice will subject you to an appointment change fee of contracted insurance rate or private pay fee schedule rate. This must be paid before a change in this appointment can be made. We schedule up to 60 minutes for this appointment and last-minute cancellation keeps us from serving others who are waiting to see your doctor.

We kindly ask that you do not cancel this appointment without appropriate notice.

If you have any other information about past evaluations, please bring a copy for the doctor or email prior to the scheduled appointment to: vortexpsychiatry@outlook.com.

The charge for the initial evaluation is $465.00 with no insurance coverage. We require a credit card on file is required for all exisiting and new patients.

Please be sure that the physician you are seeing is a provider for your insurance. We do not guarantee coverage if your insurance considers the physician out of network.

For child evaluation, please ask a teacher who knows your child best to fill out the Teacher questionnaire in your packet. The teacher can either give the form back to you or mail it to us directly. If your child is young, please bring a game, toy or books. A caretaker while parents are talking to the doctor may also be appropriate.

Thank you.

Said A. Ibrahimi, M.D.

Please fill out the intake packet before your appointment. Please also bring copies or email to: vortexpsychiatry@outlook.com of all past testing, psychiatric or psychological treatment records, school/college records and psychiatric inpatient records/discharge summaries, if applicable.

About the evaluation

There are no standard psychological or laboratory tests by which one can make a psychiatric diagnosis. The diagnosis is made by listening to the presenting concerns, going over the records, looking into family and patient's history, conducting interviews with the patient, the family, and others, if necessary.

The initial evaluation will help you determine

What may be the underlying reason for the problems? Are there any psychological, medical, neurological, or genetic problems underlying the condition? Do the problems present a psychiatric disorder or a variant of normal behavior? What can be done to address the problems and what will happen if we do nothing?

The initial evaluation takes approximately one hour, sometimes longer, and consists of:

Patient and family interview
Discussion of findings and presentation of diagnostic impression
Treatment recommendations

The evaluation will give you a good understanding of what's going on. There are many ways to deal with the problems. Many patients and families are uncomfortable about psychiatric medications. We want you to know that medications are not always recommended and often are not even appropriate. The decision about the medication depends on the nature and severity of the problems, the patient's age, associated issues, but ultimately, on the best available treatment option.

If a medication is prescribed, you will be scheduled for follow-up appointments in one week to one month’s time, depending on the problems and the prescribed medication(s).

We look forward to seeing you and hope that we can be of service.

INSURANCE INFORMATION:

Guarantor Name:

Date of Birth:

Primary Insurance:

Insurance identification number

Policy, Group, or Local

Insurance Provider Phone Number:

Financial Responsibility Form- Credit Card Authorization

Responsible Person’s Name

Cardholder Name

Card Type

VISA/MASTER CARD/AMEX/DISCOVER

Card Expiration Date

Zip Code for Cardholder Billing

Phone Number

area code and number

Guardian/Parent Employer Name

Employer Address and Phone Number

I will be responsible for all bills for this patient, no matter who brings the patient to the office, such as when brought by caretakers, grandparents, stepparents, ex-spouse etc., as long as the services provided are for the benefit of the patient. I understand that if my Insurance plan refuses to cover services given to me by this office, I will be responsible for the charges.

I will provide a current credit card on file. I allow the office to charge fees not covered by the insurance such as for lack of coverage, yearly admin charge, deductibles, unpaid copays, and no-show charges. A statement of such charges will be sent to you.

I agree to pay all bills as presented and all reasonable fees associated at the time with the with collection of such charges including fees for bounced checks, rush Rx, copays, phone consultation charges not covered by insurance, same day cancellation and noshow fees, request for copy of records, school form filling etc. per schedule of fees attached currently in force.

Signature

Date

Relationship to patient (if other than patient):

Dear Patients,

This letter is to inform you of our updated billing practice regarding receiving patient payments. Effective January 2015, we now require a credit or debit card to be on file with our office for full patient payment of services at each appointment.

Why the change? There are several reasons for this change. With the changing environment in healthcare, in particular the Affordable Care Act and High Deductible Health Plans (HDHPs) more responsibility of payment is being placed on the patient. We need to be sure that patient balances are paid in a timely manner. To do this, we need to ensure we have a guarantee of payment on file in our office.

What is a Deductible and How Does It Affect Me? An annual deductible is the dollar amount you must pay out of pocket during the year for medical expenses before your insurance coverage begins to pay. For example, if your policy has a $2,000 deductible, you must pay the first $2,000 of medical expenses before the insurance company begins to pay for any services. This works just like the deductible for your car insurance or homeowner’s insurance policy does.

When do I have to pay for services? Any time you receive medical care, you will be expected to pay in full for your services until your deductible is met. If you have a very large deductible, called a high- deductible insurance plan, you may have to pay out of pocket for most of your primary care services.

How will I know when my deductible has been met? You can call your insurance company at any time to check on how much of your deductible has been met and some insurance companies have this information available online. Every time you receive medical services, you will receive notification from your insurance company with how much they paid or did not pay if the amount went to your deductible when they send you an Explanation of Benefits (EOB.)

How will I know how much you are going to charge me? You will receive a letter in the mail (or e-mail) from your Insurance carrier that explains how much of your office visit they pay and how much you pay. This is called an Explanation of Benefits (EOB.) This letter tells you exactly, according to your health insurance coverage, how much of your health care bill is your responsibility and how much is the responsibility of your insurance to pay.

Then what? We receive the same Explanation of Benefits (EOB) that you do. Most Insurances will send your EOB prior to us receiving our copy. It arrives about 10-20 days after your appointment has been billed. We look at each EOB carefully and determine what your insurance has determined as patient responsibility. This is the same way we normally determine how much to send you a statement for in the mail. All patients with commercial insurance are required to keep a credit or debit card on file. If you do not wish to keep a card on file, we will expect an estimated payment at the time of service. For example, if your commercial insurance requires $190.00 to be paid for standard service and your deductible is not met, you will be expected to pay the $190.00 via check or credit card before you are seen, but this will not include ancillary charges that may arise out of your visit. Once we receive the Explanation of Benefits (EOB) on your visit, we will send a statement if your patient responsibility is higher than the originally collected amount or you will have a credit on your account if your patient responsibility is lower than the originally collected amount. Once we receive the insurance EOB for your visit, we will charge the credit card on file the exact amount as per the EOB that is stated to be patient responsibility. Once charged, we will email you a receipt of payment.

Consent to Release and Exchange Information

If you have seen other professionals regarding this problem and would like us to co-ordinate with them, please provide us this consent.

For young patients, his or her pediatrician must be added.

Patients First Name

Patients Last Name

Is Patient over 18 years old?

If no, Guardian’s Name

I am requesting you to provide all pertinent medical information about the patient listed above to Said A. Ibrahimi, Vortex Psychiatry. This information may be in electronic from such as a PDF file sent via email (vortexpsychiatry@outlook.com) Fax or by hard copy mailed to above address.

I am giving my consent to both parties to share and exchange information as appropriate for the care of the patient

Professional / Specialty /Family

Provider Name and Specialty

example: Primary Care, Pediatrician, etc.

Address

City & State

Zip

Office Phone Number

Office Fax Number

Office Email address

Office Website

Guardian/Parent Signature

Date

Office Policies and HIPAA Policy Acknowledgement

Our HIPAA policy is posted on our website: www.VortexPsychiatry.com.com. Please be sure to read it.
The office staff is available to answer your call from 9:00 a.m. 4:00pm. Monday thru Thursday, and we are available by email as well: VortexPsychiatry@outlook.com
We use an electronic reminder service for your upcoming appointment. The reminders will come via email.
A $69 admin fee is charged yearly for all accounts. This fee is not billable to insurance and needs to be paid on your first visit of the year.
We charge $175.00 for all changes and cancellation of appointments with less than 24- 48 hours business-day notice. There are no exceptions for this (including sickness, work travel etc.) This is a typical policy for psychiatric offices where a considerable time is set aside with no double booking.
You may email us about yourself or the patient if you wish. Please clearly indicate the patient name and the doctor to whom your communication is directed. The doctors review the emails daily in most cases. If it is urgent, please call the office instead of emailing. Standard emails are not hack-proof but are considered HIPPA compliant.
Refills are done using electronics means. This is secure and avoids errors. Please do not call the office for refills.
Most Rx refills require regular follow-up as suggested by the doctor. Rx refill requests must be made in writing via website or email.
For medication refills (Schedule II medications) we require a 3-5 business day notice (Not including Friday thru Sunday as we do not refill or review request on these days).

Guardian/Parent Signature & Date:

If you will be using your medical insurance to pay for visits to this office….

Insurance coverage is for a particular doctor and not the office.
If your insurance changes, let us know immediately. Transactions older than 90 days cannot be billed to insurance.
If you have any other insurance plan, please send the superbill given to you by the office to your company. They will reimburse you directly based on your deductible and out of network coverage.
We require a credit card on file for timely payment of amount due to this office for all unpaid charges.
We do not verify or guarantee your coverage. This is your responsibility.
If you are seen by the doctors and your insurance deems the charges not covered, you are responsible for them.
Please check with your insurance as to what your deductible is. During the first quarter of the year, you are expected to pay the contracted rate at the time of service. We require full payment of agreed upon rate at time of visit if you have not met your deductible.
Phone consultations over 10 minutes are charged. Your insurance most likely will not over these.
Some services such as phone consultations with other providers, review of records, no- show charges, cancellation fees, form filling, reports etc. are often NOT a reimbursable expense. If these services are used or requested by you, you are responsible for their charge.
If after billing your insurance company we find that you do not have coverage, have not met the deductible, or for any other reason, the amount due will be charged to your credit card on file after 30 days.
Please call your insurance and make certain that you are covered for seeing this office, the doctor with whom you have the appointment and understand clearly your deductibles and your coverage. For purposes of meeting your deductible, please be advised that typical charges from this office may be app. $1500 per year.

Insured’s Signature & Date

Please read carefully and sign. This is a required form if you want us to bill your insurance.

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 or Guardian Signature:

Date

Message to our patients about the Arbitration Agreement

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.

Guardian/Parent Signature:

Date

Family History Questionnaire

Patient's First and Last Name

Patient's Date of Birth

Age

Gender

Male Female

Height

Weight

Form is completed by Name of Person / Relationship to Patient

List your questions and concerns:

Family Information

Child lives with

Parent 1

Age

Education (highest degree)

Occupation

Parent 2

Age

Education (highest degree)

Occupation

Parent 1

Biological Step Adoptive Foster Not at home

The parents are

Married Separated Single Divorced

Custody arrangement, if applies

Biological parents, if different from above

Parent 1

Age

Education (highest degree)

Occupation

Parent 2

Age

Education (highest degree)

Occupation

Brothers (indicate if half or step)

Sisters (indicate if half or step)

Anyone else in living in the household?

List major psychiatric disorder (depression, anxiety, OCD, schizophrenia, ADHD, alcohol or drug abuse, psychiatric hospitalizations; also include suicide, homicide, and major legal offences) in close members of the family biologically related to the patient.

Relation

Age

Problem

Relation

Age

Problem

Relation

Age

Problem

Information about school

Name of School

Grade

Type of Class

City

School Phone Number

Teacher(s) Name(s)

School History (Specify behavioral and academic problems, repeated grade, comments)

Age, Grade, School, and Comment

Past Medical History

Patient's Primary Care Physician:

Phone

Address

Other Physicians and Therapists currently involved in your care

Name

Specialty

Phone

Address

Name

Specialty

Phone

Address

Neonatal History (list all significant issues related to pregnancy, birth, and immediate post-partum period, including prematurity, forceps delivery, meconium, birth trauma, jaundice, colic, etc.)

Medical (list any significant illnesses, surgeries, and hospitalizations (incl. head injuries, seizures, vision or hearing loss, etc.)

Medication and Treatment History

Past medications List, in chronological order, all psychiatric medications the patient took in the past. If the list is long, print it separately and bring it to your appointment.

Current medications List ALL medications (including prescriptions, OTC, vitamins, herbal, topical, etc.)

List any non-medication treatment the patient has undergone

CHILD AND ADOLESCENT RATING SCALE (PCC-CARS)

Patient's Full Name

Age

Patient's Date of Birth

Major concerns (check all that apply):

Attention

Behavior

Academic

Social

Others (please specify):

Please rate the behaviors:

0 – Never (None)

1 – Sometimes (Mild)

2 – Often/Always (Severe)

(circle the most appropriate number)

Block I

Easily distracted from task

0 1 2

Difficulties focusing, can't start

0 1 2

Poor attention to details, careless mistakes

0 1 2

Forgetful, loses personal things

0 1 2

Poor planning, wastes time

0 1 2

Daydreaming, in his/her thoughts

0 1 2

Shifts from one activity to another

0 1 2

Leaves work unfinished

0 1 2

Can't wait for his/her turn

0 1 2

Fidgets and squirms

0 1 2

Talks excessively, can't stop

0 1 2

Moves constantly, can't sit still

0 1 2

Likes sameness, routine, no changes

0 1 2

Extremely stubborn

0 1 2

Transitions are difficult

0 1 2

Very sensitive (to loud noise, tags,smells)

0 1 2

Perfectionist, works slow

0 1 2

Block II

Argues with parent, adults

0 1 2

Refuses rules

0 1 2

Loses temper, gets angry, screams

0 1 2

Feelings are easily hurt, gets frustrated

0 1 2

Gives up easily

0 1 2

Deliberately vandalized property

0 1 2

Lies, "cons" to get what (s)he wants

0 1 2

Bullies, intimidates others

0 1 2

Have stolen from a store, others

0 1 2

Got into fights, used a weapon

0 1 2

Physically cruel to people & animals

0 1 2

Callous, feels no guilt

0 1 2

Smokes, drinks, drugs

0 1 2

Truant from school

0 1 2

Has been arrested, committed an illegal act

0 1 2

Block III

Tics are involuntary, rapid, repetitive, purposeless movements or vocalizations

Eye blinking

0 1 2

Facial movements

0 1 2

Head or body jerking

0 1 2

Nervous coughs, grunts, snorts

0 1 2

Bites nails, cracks knuckles, picks skin

0 1 2

Chews on cloths

0 1 2

Obsessions are recurrent, unpleasant thoughts Compulsions are behaviors to stop obsessions or other anxious thoughts.

Can't get mind of certain thoughts

0 1 2

Fears that might do something bad

0 1 2

Concerned about order and neatness

0 1 2

Stores things, can't discard them

0 1 2

Repeats certain acts over and over

0 1 2

Block IV

Always worries about everything

0 1 2

Always tense, needs lots of reassurances

0 1 2

Very shy and timid, clingy

0 1 2

Extremely self-conscious (worries what others are thinking/saying about him/her)

0 1 2

Easily embarrassed and sensitive to criticism

0 1 2

Had panic attacks in the past

0 1 2

Excessive fear of dark, heights, bees, etc.

0 1 2

Had separation problems as a child

0 1 2

Nervous stomach, headaches

0 1 2

Family history of anxiety, panic, and social phobia

0 1 2

Excessive tiredness, daytime sleepiness

0 1 2

Block V

Irritable, touchy, grouchy, easily angry

0 1 2

Unhappy most of the day, most days

0 1 2

Cries easily, has sad thoughts

0 1 2

Talks about dying, sad themes in play

0 1 2

Talks about wanting to die

0 1 2

Feels things will never get better

0 1 2

Does not enjoy anything anymore

0 1 2

Major changes in sleep and appetite

0 1 2

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

0 1 2

Feels guilty, too hard on self

0 1 2

Feels that be better off dead

0 1 2

Harmed self (cutting, scratching, burning)

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 quiet

0 1 2

Brags, shows off, reckless

0 1 2

Goes through uncontrollable rages

0 1 2

Early preoccupation with sex

0 1 2

Family history of depression or bipolar disorder

0 1 2

Block VI

Talks to self, hears what others can't hear

0 1 2

Feels others are out to get him/her

0 1 2

Strange, bizarre, odd behavior, talk

0 1 2

Believes in reading minds

0 1 2

Has strange, bizarre ideas

0 1 2

Block VII

Bedwetting

0 1 2

Soils underwear

0 1 2

Sleeps too much, always tired

0 1 2

Hard time falling asleep

0 1 2

Sleepwalking, -talking, night terrors

0 1 2

Block VIII

Socially awkward, misses social cues

0 1 2

Does not look in the eyes

0 1 2

Prefers playing alone, refuses group activities

0 1 2

Bullies, provokes fights, teases others

0 1 2

Block IX

School work is hard, confusing

0 1 2

Behind in reading, math

0 1 2

Had to repeat a grade or was held back

0 1 2

Homework takes all night to finish

0 1 2

Additional Comments:

School Performance and Achievement (to be completed by teacher)

Dear Teacher,

Thank you for taking time to fill this questionnaire for:

Name

Date

Your input is most valuable to us in the assessment of student's learning and social needs. Please return this completed for to the parent(s) or main it back to us at the above address. It will be shared with the family upon request.

Student's Name

Grade

School Name

Address:

Phone

Type of Classroom/Services (reg., SDC, RSP, etc.)

Briefly describe student's academic work habits

Student's response to classroom rules, instructions

Briefly describe interactions with other students, school friends

Academic Achievement (Current Level of daily achievement in class)

Comments

Most Recent Achievement Tests

Additional tests performed in school (IEP, Speech, and Language, etc.)

What concerns you most about this student?

Student’s strengths

Student's deficits

Additional comments

Form Completed by Name

Title