Vortex Psychiatry- Adult Intake

Prospective New Patient Demographics

In preparation for your first visit with Said A. Ibrahimi, M.D., Vortex Psychiatry, 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 Email

Patient Address (Street)

City, State, Zip Code

Best Contact Cell 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:

Who were you referred by?

Insurance

Please email a copy of the front and back of the insurance card to:

VORTEXPSYCHIATRY@OUTLOOK.COM

Insurance Name

Insurance Subscriber ID Number

Insurance Group Number

Please include Mental Health/Provider Services Phone Number: (Can be found on front or back of insurance ID card)

ADDIONTAL INFORMATION:

Submit copies of all past testing, psychiatric or psychological treatment records, school/college records and psychiatric inpatient records/discharge summaries, if applicable to: vortexpsychiatry@outlook.com

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, reviewing the 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 the 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 in time, depending on the problems and the prescribed medication(s). We charge an annual fee of $99.00 at your first date of service, and once a year thereafter.

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

Warm Regards,

Said A. Ibrahimi M.D.

Vortex Psychiatry

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 9 AM to 4:30 PM. Monday through Friday. We are available by email at vortexpsychiatry@outlook.com.
Charges indicated below indicate the cancellation of appointments with less than 1 business-day notice and or same day no show/cancellation. 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.
Fees are as follows for no call- no show- less than 24 hours-notice to cancel or reschedule your appointment.$190.00 per occurrence for an established patient. If you are late or no show, same day cancell for your initial appointment, there will be a fee of up to $465.00.
We use an email reminder service for your upcoming appointment. The reminders will come via email and or an auto remind service. Please check your junk/spam email box as well.
After the 4th occurrence potential discharge of care from Dr. Ibrahimi. Per Dr. Ibrahimi's discretion.
You may email us about yourself or the patient if you wish. Please clearly indicate the patient’s name and date of birth and best contact number. All emails will be responded to within 1-2 business days. The doctor reviews emails daily in most cases. If it is urgent, please call the office instead of emailing at 925- 648-2650. Standard emails are not hack proof but are considered HIPAA compliant.
Refills are done using electronics means. This is secure and avoids errors. Please do not call the office for refills. Visit our website to view our medication refill policy.
Most prescription refills will require regular follow-up as suggested by the doctor. Medication refill requests must be made in writing via website or email.
For medication refills can take the minimum 3-5 business days to be viewed and process. Please see our website for full details regarding Refill Request.

Patient's Signature

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:

Financial Information

Name that appears on credit card

Credit Card Type

VISA/MC/AMEX/DISCOVER

Credit Card Number

Credit Card Expiration Date

CVV

Credit Card Zip Code

Financial Responsibility

Financial Responsible: First and Last Name

Financial Responsible Date of Birth:

Best Contact Phone:

Email address:

The office will keep a current credit card on file. I allow the office to charge fees not coverable by the insurance such as for non-coverage, yearly admin charge, unmet 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 collection of such charges including fees for returned checks, rush prescription, yearly admin charges, copays, phone consultation charges not covered by insurance, same day cancellation and no-show 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)

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

Name

Best contact phone:

Email:

Relationship to a patient

List the reason(s) for seeking help at this time (when started):

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

MEDICAL HISTORY

How would you rate your general health?

Excellent

Good

Fair

Not so good

Very bad

Have you had any of the following treatments below?

TMS Therapy

ECT

CBT/DBT

In patient treatment/ Partial Hospitalization/IOP

How would you rate your heart health?

Excellent

Good

Fair

Not so good

Very bad

How would you rate your endocrine health?

Excellent

Good

Fair

Not so good

Very bad

Do you have serious or chronic medical conditions?

Yes No

Have you had an accident, injuries, including head injuries?

Yes No

Please list all other diagnosis below:

List all Medications, Vitamins, Supplements:

Include frequency and dosage

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

Describe your sleep hygiene:

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

Alcohol and Other Drug use. 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)

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

Yes No

If yes, please describe

List the date of your last lab work and types of labs taken:

Have you had your annual exam with your Primary Care Provider, if so when?

Major concerns (check all that apply):

Attention

Relationships

Professional

Health

Memory and thinking

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.

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