Karen Hernandez, Ph.D.

12750 SW 2nd St. Suite 202, Beaverton, OR 97005

Phone: 503-803-9530, Fax: 503-642-3179,

Client Information Form

Today’s Date:

Identification

Youth’s name: Date of Birth: Age:

Ethnicity/Race: Sex:

Nickname: Social Security #:

Home street address: Apt.:

City: State: Zip:

Home phone: Mobile phone:

Parent’s Email:

Please indicate any restrictions on calls or emails:

Emergency Contact Information

Name: Phone:

Address:

Relationship to you:

Referral (Who gave you my name to call?)

Name: Phone:

Address:

May I have your permission to thank this person for the referral?  Yes  No

Chief concern

Please describe the main difficulty that has brought you to see me:

Youth’s medical care (From whom or where does your child get medical care?)

Clinic name: Phone:

Doctor’s name:

Address:

If you enter treatment with me for psychological problems, may I tell your child’s medical doctor so that he or she can be fully informed and we can coordinate your treatment?  Yes  No

Youth’s School

School: Phone:

Address:

Grade in School:

Counselor: ______

Please indicate any restrictions on calls:

Past Psychological/Psychiatric Treatment

Have your child ever received psychological, psychiatric, drug or alcohol treatment, or counseling services? Please indicate both inpatient and outpatient treatment.  Yes  No
If yes, please indicate:

Yes / No / Types of Treatment / When? / Was it helpful? / Reason for treatment?
Outpatient Counseling
Medication (mental health)
Psychiatric Hospitalization
Drug/Alcohol Treatment
Self-help/Support groups
List of Symptoms

Please circle any of the following that have been bothering you lately.

  • Significant weight change
  • Feeling of worthlessness
  • Guilt/Shame
  • Indecisiveness
  • Recurrent thoughts of death
  • Attempted suicide
  • Irritability
  • Excessive Anger
  • Lack of friends
  • Homework issues
  • Seasonal mood changes
  • Excessive talking
  • Restless, can’t sit still
  • Hyperactivity
  • Racing thoughts
  • Great increase in energy, activity
  • Wide mood swings
/
  • Flashbacks of previous traumatic experiences
  • Nightmares
  • Re-experiencing traumatic events
  • Numbing
  • Always on alert, scanning my surroundings
  • Startle easily
  • Avoidance
  • Memory lapses
  • Intrusive thoughts, impulses you can’t control
  • Same thoughts over and over
  • Repetitive behaviors
  • Racing heart
  • Anxiety
  • Sweating, shaking
  • Chest pain, shortness of breath
/
  • Nausea
  • Dizziness
  • Fears
  • Can’t relax
  • Worry about things over and over
  • Panic
  • Day dreaming
  • Lack of concentration and focus
  • Disorganization
  • Lack of follow through
  • Distractibility
  • Careless mistakes
  • Not listening
  • Losing objects and forgetful
  • Low frustration tolerance
  • Parenting divorce
  • Parent-Child problems
/
  • Interrupting
  • Intrusiveness and being driven
  • Perfectionism
  • Hearing voices that other’s don’t hear
  • Seeing things others don’t see
  • Restricted food intake
  • Compulsive/ binge eating
  • Purging/laxatives/extreme exercise
  • Body dissatisfaction
  • Desire to be very thin
  • Loud
  • Drugs/Alcohol

Please indicate how the issue(s) for which you are seeking treatment are affecting the following areas of your life

No effect / Little effect / Some effect / Much effect / Significant effect / No applicable
Family / 1 / 2 / 3 / 4 / 5 / n/a
School performance / 1 / 2 / 3 / 4 / 5 / n/a
Friendships / 1 / 2 / 3 / 4 / 5 / n/a
Physical health / 1 / 2 / 3 / 4 / 5 / n/a
Anxiety level / nerves / 1 / 2 / 3 / 4 / 5 / n/a
Mood / 1 / 2 / 3 / 4 / 5 / n/a
Eating habits / 1 / 2 / 3 / 4 / 5 / n/a
Sleeping habits / 1 / 2 / 3 / 4 / 5 / n/a
Alcohol / drug use / 1 / 2 / 3 / 4 / 5 / n/a
Ability to concentrate / 1 / 2 / 3 / 4 / 5 / n/a
Ability to control anger / 1 / 2 / 3 / 4 / 5 / n/a
Family Relationships

Biological Father: ______

Present age: ____Occupation: ______

Relationship Information: ______

Biological mother: ______

Present age: ____Occupation: ______

Relationship Information: ______

Stepparents (if applicable) ______

Present age: ______Occupation:______

Relationship Information: ______

If your child is from a divorced home, how old was your child when the divorce occurred? How did she or he respond to the divorce?

Other

Is there anything else that is important for me as your therapist to know about and that you have not written about on any of these forms? Please tell me here; use more paper if needed.

______

This is a strictly confidential patient medical record. Re-disclosure or transfer is expressly prohibited by law.Pg 1

090409

Karen Hernandez, Ph.D.

12750 SW 2nd St. Suite 202, Beaverton, OR 97005

Phone: 503-803-9530, Fax: 503-642-3179,

Medical and Developmental Information Form

Developmental History

Is your child adopted? YesNo

If yes, please provide details:

Were there any complications during pregnancy or delivery (if known): YesNo

If yes, please explain:

Were substances used during pregnancy (if known)?YesNo

If yes, please explain?

Were there any problems with your child’s development?

___ Motor development (walking, coordination, balance)

___ Speech development (stuttering, speaking)

___ Sensory development (vision, hearing, reaction to noises)

___ Cognitive development (unusual thoughts, odd ideas/fantasies)

___ Academic development (learning problems, ADHD)

Family History

Is there a family history of any of the following?

___ Aggression/Oppositional behaviorIf yes, who?

___ Attention, Overactivity, impulsivityIf yes, who?

___ Learning problemsIf yes, who?

___ Psychosis/SchizophreniaIf yes, who?

___ DepressionIf yes, who?

___ Anxiety problems, Excessive worriesIf yes, who?

___ SuicidalityIf yes, who?

___ Legal problemsIf yes, who?

___ Substance abuseIf yes, who?

Social

How does your child do socially?

This is a strictly confidential patient medical record. Re-disclosure or transfer is expressly prohibited by law.Pg 1

090409

Karen Hernandez, Ph.D.

12750 SW 2nd St. Suite 202, Beaverton, OR 97005

Phone: 503-803-9530, Fax: 503-642-3179,

Insurance Information Form

Patient Information

Patient name: Date of Birth: Age:

Social Security Number:

Home street address: Apt.:

City: State: Zip:

Primary Insured Identification Check if self 

Name: Phone:

Address:

Relationship to you: Date of Birth:

Insurance Company Information

Insurance Company:

Address:

Customer Service Phone:

Primary Insured ID#: Group ID#:

Karen Hernandez, Ph.D., has my permission to bill my insurance company. I authorize Karen Hernandez, Ph.D. to release any information necessary to process my claims. I further authorize that my insurance benefits be paid directly to Karen Hernandez, Ph.D., LLC.

Signature Date

Verification of Benefits for office use only

Date: Name of Insurance Rep:

Effective Date of Policy:

Deductible: Applies?  Yes  No Deductible Amt used:

Co-pay: Sessions allowed: Used:

Treatment plan required:  Yes  No After sessions

Notes:

This is a strictly confidential patient medical record. Re-disclosure or transfer is expressly prohibited by law.Pg 1

090409

Karen Hernandez, Ph.D.

12750 SW 2nd St. Suite 202, Beaverton, OR 97005

Phone: 503-803-9530, Fax: 503-642-3179,

Billing Information Form

Patient Information

Patient name: Date of Birth: Age:

Social Security Number:

Payment Plan

I agree that payments or co-pays for services are due at the time of service and the responsibility for payment is mine. Denial of payment by an insurance carrier or other third party does not waive my responsibility to pay. I agree to pay in full with check/cash for the session or co-payment at the time of services. My credit card will be charged for payments 30 days or more past due.

Signature of Client: ______

In addition, I wish to have my insurance carrier or third-party billed. Please initial below.

I elect to have an insurance carrier or other third party billed on my behalf. I authorize that any balance outstanding 90 days after billing will be charged to my credit card.

Finally, I understand that no show or late cancelled sessions (less than 24 hours notice) will be charged $75. Please initial below.

I authorize that the fee for any late cancelled/no show sessions will be charged to my credit card.

Credit Card Information / Required

I authorize Karen Hernandez, Ph.D., LLC, to charge this account for services according to the payment plan agreed above:

Card Number:

Expiration Date: (Mo. Yr.) 3-digit CID: (on back of card)

Name of card holder:

Signature of card holder:

Address of card holder:

Signature of client (if different):

Witness: Date:

This is a strictly confidential patient medical record. Re-disclosure or transfer is expressly prohibited by law.Pg 1

090409

Karen Hernandez, Ph.D.

12750 SW 2nd St. Suite 202, Beaverton, OR 97005

Phone: 503-803-9530, Fax: 503-642-3179,

Please take a few minutes to review my policies and procedures. This information introduces you to my practice and may help answer questions you may have. If you have further questions after reading this or individual concerns not covered here, please feel free to ask me about them at any time. I am in the independent practice of psychology.

Credentials

I have a Doctorate degree from Texas A&M University and am licensed as a Psychologist by the Oregon Board of Psychologist Examiners. As a licensed psychologist by the Oregon Board of Psychologist Examiners, I adhere to the APA Revised Code of Ethics. I also follow treatment standards of the American Psychological Association. I have expertise and training in the use of a variety of psychological interventions to assist clients in dealing with and/or overcoming their mental health issues. I have provided mental health services to children and adults for over 10 years, in a variety of settings. My training and experience include individual, couple, and family therapy. If you have any questions about my procedures or professional background, we should discuss them whenever they arise.

During the first few sessions, I will discuss with you my approach to psychotherapy, as well as the risks, benefits, and other important aspects. I view therapy as a collaborative effort between therapist and client. Once the goals of therapy are determined through collaboration, we will develop a treatment plan together. At the beginning of treatment and throughout various times during treatment, I may ask that you fill out a short questionnaire to help evaluate if the treatment is effective. This helps us be able to tailor the goals and treatment to best meet your needs.

Treatment Options and Risks

There are many different models that I use to deal with problems that you hope to address. Psychological treatment can have benefits and risks. While therapy has been shown to have many benefits including improving relationships, solutions to specific problems, and significant reduction of feelings of distress, there are no guarantees of what you will experience. There are also risks involved in therapy. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. As you deal with problems in therapy you could experience an increase in stress or anxiety. As change occurs, sometimes problems seem to get worse before they get better. While you consider these risks, you should know that many people find therapy very beneficial and clinical research has shown therapy to generally be very effective.

My Miniature Schnauzer, Gino, often accompanies me to my office to provide canine-assisted therapy. Substantial research studies have demonstrated the importance of the human-animal bond; studies also indicate that just being in the presence of an animal companion can have a positive therapeutic impact on people including improvements in mental, social, and physiologic health. For those clients who are interested in canine-assisted therapy, Gino can be petted or cuddled with during counseling sessions; however, clients do not have to have any interaction with Gino, and he can be leashed and kept at a distance from clients who are not comfortable with dogs or have pet allergies. Please let me know if you have any concerns or questions regarding Gino or canine-assisted therapy.

Sessions

My practice operates by appointment only. Each session is typically 45 minutes. If you are unable to keep an appointment I request you give me 24 hours notice. Cancellations within 24 hours of the appointment time will be billed to you. Your insurance company will not pay for missed appointments.

Confidentiality

The information shared with me is considered private and confidential and will not be shared with anyone unless you have given written permission. There are some exceptions to this confidentiality, when information may be shared without your permission. These exceptions include:

  1. It is legally required of me to act so as to prevent physical harm to others or to society when there is “clear and imminent” danger of that happening.
  2. I am ethically bound to act to protect you and others from harm
  3. I am ethically bound to report cases of ongoing child, elder, and disabled abuse
  4. I may have to release clinical records regarding your treatment to insurance carriers as required for payment or review of your claim
  5. I may have to release your records when ordered to do so by court order.
  6. I may use electronic transmission to send treatment plans, reports or evaluations to your insurance company, specific agencies, or other providers.
  7. It should be noted that email correspondence should not be considered confidential due to the security of these communications.

Attached is a Notice of Privacy Practices. This notice explains the Health Information Portability and Accountability Act (HIPAA), a federal law that provides privacy protections with regard to the use and disclosure of Protected Health Information (PHI) used for the purposed of treatment, payment, and health care operations.

Ending Therapy

You normally will be the one who decides therapy will end, with three exceptions. If we have contracted for a specific short-term piece of work, we will finish therapy at the end of that contract. If I am not in my judgment able to help you, because of the kind of problem you have or because my training and skills are in my judgment not appropriate, I will inform you of this fact and refer you to another therapist who may meet your needs. If you do violence to, threaten, verbally or physically, or harass myself, the office, or my family, I reserve the right to terminate you unilaterally and immediately from treatment. If I terminate you from therapy, I will offer you referrals to other sources of care, but cannot guarantee that they will accept you for therapy. If I must discontinue our relationship because of illness, disability, or other presently unforeseen circumstances, I ask you to agree to my transferring your records to another therapist who will assure their confidentiality, preservation, and appropriate access.

Other Services

In addition to psychotherapy, I also do psychological assessments. Psychological assessments are

different from psychotherapy and we will discuss which service I am providing. During apsychological assessment we will have a few appointments together (usually 2-3) focused on aspecific referral question. At the end of our time together, I will write a report and send it to theprovider who requested the assessment. During our time together I will ask you many questions,some of which may not seem like they are related to the issue being assessed. I may also ask youto complete one or more questionnaires or give you some tests, depending on the referralquestion. All of the same rules of confidentiality described in the “About Confidentiality” sectionstill apply.

What to Expect from Our Relationship

The relationship between client and psychologist is unique because it is designed to help theclient increase their well-being. The relationship can become emotionally intense whichincreases its capacity to heal but also requires certain constraints to protect the client’s wellbeing.Towards this end I follow the ethical standards of the American PsychologicalAssociation (APA). Let me explain these limits, so you will not think they are personalresponses to you.

First, I am licensed and trained to practice psychology—not law, medicine, finance, or any other

profession. I am not able to give you good advice from these other professional viewpoints.

Second, state laws and the rules of the APA require me to keep what you tell me confidential (that is, private). You can trust me not to tell anyone else what you tell me, except in certain limited situations. I explain what those are in the “About Confidentiality” section of this brochure. If I see you on the street or socially, I may not say hello or talk to you very much. This is not a personal reaction to you, but rather a way to maintain the confidentially of our relationship.

Third, in your best interest, and following the APA’s standards, I can only be your therapist. I cannot have any other role in your life. I cannot, now or ever, be a close friend or socialize with any of my clients. I cannot be a therapist to someone who is already a friend. I can never have a sexual or romantic relationship with any client during, or after, the course of therapy. I cannot have a business relationship with any of my clients, other than the therapy relationship. Even though you might invite me, I will not attend your family gatherings, such as parties or wedding.

Fees

My fee for the intake session is $200/hr. Follow-up session for individual, family or couple therapy is $165/hour. Comprehensive psychological evaluations are billed at an hourly rate of $180 and typically require anywhere between 8-10 hours. Your health insurance may cover a portion of the fee, but you are still responsible for your deductibles and co-payments, as well as determining your insurance coverage for a psychological treatment. As a courtesy to you and whenever possible, I will file the insurance claim for you. However, I cannot accept responsibility for collecting an insurance claim or for negotiating a disputed claim. Insurance reimbursement is a contract between you and your carrier. Your signature on this form authorizes me to bill your insurance company and responsible parties for services and to have payment assigned to me.

Unless other arrangements are made, clients are expected to pay for each session or co-payment at the time of services. I obtain credit/debit card information from clients to be used for late cancels and no-shows and for balances over 30 days old. Outstanding balances with an insurance carrier of more than 90 days will also be charged to client’s credit cards. If you think you may have trouble paying your bills on time, please discuss this with me. If your unpaid balance reaches $250, I will notify you by mail. If it then remains unpaid, I must stop therapy with you.

If your bill is not paid as agreed in this policy it may be assigned for collection action. If assigned, you agree to pay reasonable attorney’s fees and collection costs. If your bill is unpaid, your signature on this form may be considered a waiver of confidentiality for the services rendered and amount owed. A $35.00 fee will be charged on return checks.

If you need to contact me

I cannot promise that I will be available at all times. You can always leave a message on my confidential voicemail and I will return your call as soon as I can. In case of an emergency or you feel you cannot wait for me to return your call, please call the Washington County Crisis Line at 503-291-9111, 911, your primary care physician, or go to the nearest emergency.