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INTAKE FORM II - 1 Spanish

Carlos Durana, Ph.D., M.Ac.

4915 St. Elmo Ave., Suite 504 - Room 7C
Bethesda, MD 20814
301-654-0800
2265 Cedar Cove Court
Reston, VA 20191
703-408-4965
703-620-0420 (FAX)
Su condición está…
De aplicar, circula un número para indicar tu nivel de dificultad. Mínimo
Hay otros profesionales de la salud tratando esta condición? S / N
Tienes o has tenido (circula y menciona el año):
Alguna vez has tomado corticoesteroides suprarrenales (cortisona, prednisona, etc.)? S/N
Historia Médica Familiar
Musculoesquelética
Gastrointestinal
Cardiovascular
Piel y Cabellos
Ojos/Visión
Sueño
Urinario and Genital
Embarazos y Ginecología
Respiratorio
Cabeza, Oídos, Nariz, Boca, Garganta y Neurológico
General
Emocional
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CONFIDENCIALIDAD Y CONSENTIMIENTO DEL CLIENTE PARA EL TRATAMIENTO

Carlos Durana, Ph.D., M.Ac.

4915 St. Elmo Ave., Suite 504 - Room 7C
Bethesda, MD 20814
301-654-0800
2265 Cedar Cove Court
Reston, VA 20191
703-408-4965
703-620-0420 (FAX)
Pagos por Servicios: Se espera de los clientes el pago por los servicios prestados al momento de la consulta a menos que se haya llegado, previamente, a un acuerdo diferente. Los cheques deben hacerse a nombre de Carlos Durana. Usualmente, las sesiones de terapia individual tienen una duración de 50 minutos (este intervalo de 10 minutos entre una consulta y otra es utilizado por el terapeuta para archivar las anotaciones de la sesión finalizada y para prepararse para el próximo cliente).
Reembolso del Seguro Médico: Los clientes que posean seguro médico deben recordar que nuestros servicios profesionales serán cobrados al cliente y no a la compañía aseguradora. A los clientes que lo soliciten, se les entregará una factura o recibo la cual podrán presentar a su compañía de seguro para fines de reembolso.
Cancelaciones: Debido a que la programación de una consulta involucra la reservación de un tiempo específico para cada cliente, la cancelación o cambio de consultas debe hacerse con un mínimo de 24 horas de anticipación. En caso de sesiones perdidas sin previa notificación, se cobrará el valor total de la consulta.
Confidencialidad: Toda la información revelada durante las sesiones es confidencial y no puede ser divulgada a terceros sin la debida autorización por escrito del cliente, con la única excepción de que sea requerido por la Ley. La divulgación de la información debe ser requerida bajo las siguientes circunstancias: cuando exista una sospecha razonable de que el cliente representa un peligro de violencia para otros o cuando se presuma que el cliente pueda hacerse daño, a menos que se tomen otras medidas preventivas. La información podrá ser compartida con otro profesional en el caso de consulta y revisión de casos. Sin embargo, cuando esto suceda, no se utilizarán identificadores personales, como nombres.
Procedimiento de Emergencia: En situaciones en que haya riesgo de muerte o amenazas que pongan la vida en peligro, llamar primero al “911” o a la policía. Si su llamada no es una emergencia de esta naturaleza, pero necesita contactarme entre sesiones, por favor llamar a los números anteriormente mencionados y dejar un mensaje. Entraremos en contacto lo antes posible. Por favor hacer uso de estas instrucciones únicamente en caso de verdaderas emergencias.
He leído y entiendo las políticas de esta oficina y estoy de acuerdo en comenzar el tratamiento bajo las condiciones prescritas.
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CONSENTIMIENTO INFORMADO PARA PAREJA

Carlos Durana, Ph.D., M.Ac.

4915 St. Elmo Ave., Suite 504 - Room 7C
Bethesda, MD 20814
301-654-0800
2265 Cedar Cove Court
Reston, VA 20191
703-408-4965
703-620-0420 (FAX)
Entendemos que la terapia de parejas comienza con una evaluación de nuestra relación incluyendo pasado y presente de la misma. Durante esta evaluación el Dr. Durana decidirá si él es el terapeuta apropiado para nosotros, al mismo tiempo que nosotros decidiremos si deseamos o no comenzar la terapia de parejas con él. Entendemos que debido al compromiso que se requiere en cuanto tiempo y dinero además del potencial impacto en nosotros y otras personas (ver abajo), es importante hacer una elección informada al momento de escoger un terapeuta de pareja.
Hemos leído y entendemos los límites potenciales de la confidencialidad, incluyendo aquellos impuestos por las políticas del Dr. Durana y por las leyes del Estado. Hemos recibido una copia para mantenerla con nosotros. Entiendo que el rol del Dr. Durana es proveer servicios terapéuticos para que pueda sentirme mejor y/o para mejorar mi funcionamiento, especialmente cuando está relacionado con mi familia. El rol del Dr. Durana no tiene la intención de reunir información para ser usada en los tribunales ni de hacer juicios en relación a mi familia.
Por consiguiente, estoy de acuerdo en que no llamare al Dr. Durana para pedirle que proporcione records de tratamientos o para testificar en un futuro divorcio o acción de custodia. Entiendo que los tribunales pueden designar profesionales que no han tenido contacto previo con mi familia para conducir evaluaciones independientes y hacer recomendaciones al tribunal.
Entiendo que la política del Dr. Durana es no tener participación alguna en mi caso por ante un tribunal porque esto podría perjudicar nuestra relación y la habilidad de lograr mis metas. Mis metas incluyen el resolver preocupaciones personales con el fin de preservar mi matrimonio y/o para ser un mejor padre o madre. Ya que necesito hablar libremente, mi cónyuge también está de acuerdo en que nunca le pedirá al Dr. Durana testificar o presentar los records de mi tratamiento en un tribunal.
Al firmar este formulario ambos estamos acordando en no usar ninguno de mis records de intervención terapéutica o testimonio en cualquier procedimiento judicial futuro.
Entendemos todas las políticas como fueron descritas en la hoja de INFORMACION DEL PACIENTE y las aceptamos como condiciones para iniciar la terapia de pareja con el Dr. Durana.
Se nos ha dado la oportunidad de hacer preguntas y de discutir las políticas de confidencialidad y de divulgación de información con el Dr. Durana. Entendemos que mientras estemos trabajando como una pareja todo lo que uno de nosotros pueda decirle al Dr. Durana individualmente, ya sea
por teléfono o en sesiones individuales, será manejado de forma confidencial y no será compartido con el cónyuge/pareja sin el consentimiento del individuo.
Acordamos compartir responsabilidad con el Dr. Durana para el proceso de terapia, incluyendo el establecimiento y logro de metas. Al comenzar la terapia de pareja, aceptamos que ambos entendemos que trabajar hacia el cambio puede significar el experimentar sentimientos difíciles e intensos, algunos de los cuales pueden ser dolorosos, con el fin de alcanzar las metas de la terapia. Entendemos que los cambios que uno de nosotros o ambos hagamos tendrán un impacto en nuestra pareja y en otras personas alrededor de nosotros. Aceptamos que tales cambios pueden tener efectos tanto positivos como negativos y acordamos en clarificar y evaluar los potenciales efectos de cambios antes de asumirlos.
[El Dr. Durana ha explicado que su enfoque terapéutico en la terapia de pareja está en preservar y mejorar la relación en lugar de enfocarse en una felicidad individual. Si el mantenerse juntos es perjudicial para uno o ambos compañeros, el enfoque estará en facilitar una separación amigable]
Al firmar abajo, estamos de acuerdo en aceptar los servicios de ayuda mental que ofrece el Dr. Durana y aceptamos total responsabilidad por los pagos para tales servicios.
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CONFIDENCIALIDAD Y CONSENTIMIENTO DEL CLIENTE PARA EL TRATAMIENTO

Carlos Durana, Ph.D., M.Ac.

4915 St. Elmo Ave., Suite 504 - Room 7C
Bethesda, MD 20814
301-654-0800
2265 Cedar Cove Court
Reston, VA 20191
703-408-4965
703-620-0420 (FAX)
CONFIDENCIALIDAD Y CONSENTIMIENTO DEL CLIENTE PARA EL TRATAMIENTO
Confidencialidad: La Psicoterapia está diseñada de forma que sea un lugar seguro donde el cliente puede hablar sobre cualquier asunto personal que haya decido explorar. Sepa, por favor, que cualquier asunto que discutamos durante una sesión de psicoterapia será considerado legalmente como información privada y confidencial. Esto quiere decir que no divulgare absolutamente nada de lo que me diga a terceros con excepción de una de las siguientes condiciones:
a) Que usted me dé su autorización para hablar con otra persona, por ejemplo, otro profesional del área de la salud el cual le esté proporcionando algún tratamiento.
b) Que usted me diga algo que me haga sentir obligado a revelárselo a otras personas. Por ejemplo, reportar caso de sospecha de abuso a menores o ancianos; o cuando exista alguna sospecha razonable de que el cliente representa una amenaza para sí mismo o para otros.
Si usted se está consultando conmigo para terapia de pareja o de familia, Yo considero a la relación familiar o de pareja como el cliente. Durante el curso de nuestro trabajo puede ser que yo vea a alguno de ustedes individualmente para una o más sesiones o durante una parte de una sesión. Las sesiones deben ser vistas como parte del trabajo que estoy realizando con la pareja o la familia a menos que sea indicado de una forma diferente.
Adicionalmente, la ley federal conocida como The Patriot Act 2001 requiere que los terapeutas y otros profesionales en ciertas circunstancias le proporcionen al FBI archivos y otros elementos del cliente, y el FBI a su vez puede prohibirle al terapeuta revelarle al cliente que tal información ha sido requerida u obtenida por el FBI bajo tal ley.
Algunas veces consulto con otros terapeutas licenciados y con experiencia sobre cómo puedo ayudar al cliente de una mejor forma. Estos terapeutas consultados también están sujetos a las mismas leyes de confidencialidad señaladas anteriormente. Sin embargo, cuando esto es hecho, no se usa ningún identificador personal tales como nombres.
La naturaleza de la psicoterapia: La Terapia funciona más efectivamente cuando usted es una participante activo en el proceso; sepa, por favor, que le doy la bienvenida a sus comentarios o preguntas acerca de nuestro trabajo en cualquier momento. Participar en terapia puede traer muchos beneficios incluyendo, pero sin límite, los siguientes: mejores relaciones interpersonales, reducción del estrés y ansiedad, una mejor comunicación con los seres queridos, aumento de la capacidad para la intimidad, disminución de pensamientos negativos y del comportamiento de auto sabotaje, aumento de la comodidad al establecer relaciones en la familia, el trabajo y la vida social, aumento de la auto estima y auto aceptación; mayor habilidad para vivir la vida a plenitud, mayor balance en la vida; y más auto consciencia. Tales beneficios pueden requerir de un esfuerzo substancial de su parte, incluyendo participaciones activas en el proceso terapéutico, honestidad y la disposición a cambiar sentimientos, pensamientos y comportamientos tanto como sea necesario. No hay garantía de que la terapia le conducirá a alguno o a todos los beneficios mencionados anteriormente. El proceso de orientación requiere responsabilidad y compromiso por parte del terapeuta y del cliente. Usted se beneficiara mayormente de la terapia si atiende regularmente y participa activamente en el proceso de orientación. Por favor, llegue a tiempo a sus consultas y haga los arreglos necesarios en su agenda para que pueda permanecer durante toda la sesión.
La participación en la terapia puede significar cierta incomodidad, incluyendo el discutir sentimientos y experiencias, y puede evocar fuertes emociones como rabia, tristeza y miedo. Durante el proceso terapéutico muchos clientes encuentran que al inicio pueden sentirse peor antes de sentirse mejor. Generalmente es el curso normal de los eventos. El crecimiento personal y el cambio pueden ser algo fácil y rápido a veces y lento y frustrante otras veces. También puede suceder que a veces se sienta que entra en conflicto sobre si debe seguir atendiendo las sesiones o no. Si esto es el caso, le insto a manifestar sus preocupaciones para que podamos trabajar en ellas. El proceso de terapia puede conllevar veces a resultados imprevistos tales como cambios en las relaciones personales o profesionales y en las metas. Por favor esté consciente de que cualquier decisión sobre sus relaciones, vida personal o laboral son de su completa responsabilidad.
Culminación de la Terapia: la duración de la terapia depende de su situación específica y del progreso que logremos. A medida que nos aproximemos a la finalización de sus metas, discutiré con usted un plan para finalizar la terapia. Si durante la terapia usted siente que los problemas por los cuales me está viendo no están siendo resueltos satisfactoriamente y usted desea ver otro terapeuta, yo le ofreceré referencias para otros terapeutas para ayudarle a una transición suave si así lo desea. Si llega a ser claro para mí que usted no se está beneficiando de nuestro trabajo en conjunto, estoy éticamente sujeto a dejar de tratarlo y a proveerle referencias para otras fuentes de terapia. Usted puede descontinuar la terapia en cualquier momento. Si usted elige terminar su terapia, yo generalmente recomendaré que nos reunamos al menos para una visita final con el fin de facilitarle una experiencia final positive y darnos la oportunidad de reflexionar acerca del trabajo que se ha realizado.
Honorarios y política de cancelación: las sesiones de Terapia duran aproximadamente 50 minutos. Los honorarios para cada sesión se pueden pagar con cheque, efectivo o tarjeta de crédito (MasterCard/Visa). Las sesiones más largas son pro-rateadas por hora. No hay ningún cobro por consultas telefónicas breves (máximo cinco minutos), pero sesiones telefónicas más largas con usted o con otros profesionales que usted haya requerido para hablar en su nombre tendrán un cargo basado en el tiempo de duración de la llamada. Cuando marcamos una cita, ese tiempo está reservado exclusivamente para usted. Por lo tanto, si usted necesita cancelar una cita por favor hágalo con 24 horas de anticipación; de lo contrario me veré obligado a cobrar la sesión perdida ya que no tender la posibilidad de ocupar ese horario en tan corto tiempo.
Disponibilidad del terapeuta y procedimientos de emergencia: Usted puede dejarme un mensaje en cualquier momento y normalmente devuelvo las llamadas dentro de un día laboral. Si es una emergencia de vida o muerte, llamar al 911 inmediatamente.
Si tiene alguna pregunta sobre todo lo mencionado anteriormente por favor hágala. De no tener ninguna pregunta, por favor firmar abajo. Al firmar usted está reconociendo que ha revisado y que entiende completamente este acuerdo, que cualquier pregunta que haya tenido con respecto al mismo y las condiciones de este acuerdo y que das u consentimiento para participar en psicoterapia.
Nota: si usted ha impreso este formulario y lo está enviando por fax o escaneándolo e enviándolo por email, por favor firmar con su nombre en la primera línea abajo. Si usted lo está completando desde un aparato electrónico, por favor digitar su nombre en las dos líneas “firma” y “nombre imprenta”. Al hacer esto su firma electrónica indica que usted entiende y está de acuerdo con todo lo mencionado anteriormente.
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INFORMED CONSENT FOR TELE SESSIONS

Carlos Durana, Ph.D., M.Ac.

4915 St. Elmo Ave., Suite 504 - Room 7C
Bethesda, MD 20814
301-654-0800
2265 Cedar Cove Court
Reston, VA 20191
703-408-4965
703-620-0420 (FAX)

This Informed Consent for Tele health services contains important information focusing on doing psychotherapeutic services using the internet or phone. Please read this carefully and let me know if you have any questions. When you sign this document, it will represent an agreement between us.

Benefits and Risks of Tele Sessions
Tele therapy refers to providing remote therapeutic health services, using telecommunications technologies, such as video conferencing, for example, Doxy or Zoom, or telephone. One of the benefits of tele sessions is that the clinician and client can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the clinician or client takes an extended vacation, moves to a different location, or is otherwise unable to continue to meet in person. It is a pleasing option during the current pandemic situation, where your comfort is most important. It is also more convenient and takes less time. Teletherapy, however, requires technical competence on both our parts to be helpful. Although there are benefits of tele sessions, there are some differences between telepsychology and psychotherapy in person, as well as some risks. For example:

Confidentiality and Risks to Confidentiality
I have a legal and ethical responsibility to make my best efforts to protect all communications that are a part of our tele session. With the nature of electronic communications technologies being as such, I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. I will try to keep your information private but know there is a risk that our electronic communications may be unsecured, compromised, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for tele sessions and having passwords to protect the device you use for sessions).

Because tele sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. On my end I will take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in a session only while in a room or area where other people are not present and cannot overhear the conversation. It would be helpful if you could use headphones or earbuds, as they would limit the distractions from outside conversations.
The extent of confidentiality and the exceptions to confidentiality that I outlined in my Informed Consent still apply in tele sessions. Please let me know if you have any questions about exceptions to confidentiality, and I will be happy to discuss them with you.

Issues Related to Technology
There are many ways that technology issues might impact tele session. For example, technological devices may stop working during a session, or stored data could be accessed by unauthorized people or companies

Crisis Management and Intervention
Usually, I will not engage in tele sessions with clients who are currently in a crisis, where there is a need for high levels of support and intervention. Before engaging in tele sessions, we will develop an emergency response plan to address potential crisis situations that may arise during our tele work. This is for your safety.

If the session is interrupted and you are not having an emergency, disconnect from the session and I will wait a couple of minutes and then re-contact you via the tele platform on which we agreed to conduct therapy. If you do not receive a call back within a couple of minutes, then call me on the phone number I provided you (703-408-4965).

For communication between sessions, I only use email communication and text messaging with your permission and only for administrative purposes unless we have made another agreement. This means that text messages and email exchanges with my office should be limited to administrative matters. This includes things like setting and changing appointments, billing issues, and other related issues. You should be aware that I cannot guarantee the confidentiality of any information communicated by text or email. Therefore, I will not discuss any clinical information by text or email and ask that you do not either. While my email and text are my own and not accessed by anyone else, it is still important that you do not send confidential information via these means. Also, these methods should not be used in the event of an emergency.

Appropriateness of Telepsychology
At times we may schedule office in-person sessions to “check-in” with one another. I will let you know if I decide that teletherapy is not the most appropriate form of treatment for you. We will discuss options of engaging in in-person counseling or referrals to another professional in your location who can provide appropriate services. Again, your comfort level is most important. If we decide that in-person sessions are the best course of treatment, all precautions will be taken to ensure both of our safety.

We will decide together which kind of tele session service to use. You may have to have certain computer or cell phone systems to use tele session services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software necessary to take part in a tele session.

Efficacy
Most research shows that telepsychology is about as effective as in-person psychotherapy. However, some therapists believe that something is lost by not being in the same room. For example, there is debate about a therapist’s ability to fully understand non-verbal information when working remotely, I have found teletherapy to be extremely effective. I will do my best to ensure that I understand and communicate clearly and thoroughly as possible. If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call me back; instead, call 911, or go to your nearest emergency room. Call me back after you have called or obtained emergency services.

Fees
The same fee rates will apply for tele sessions as apply for in-person psychotherapy. Some insurance companies may not cover sessions that are conducted via telecommunication. As I stated in our initial conversations, I do not take insurance payments. If your insurance provider does not cover electronic psychotherapy sessions, you will be solely responsible for the entire fee of the session. No reimbursement will be made to you if tele sessions are not covered by insurance. It will be your responsibility to contact your insurance company prior to our engaging in telepsychology sessions to determine your coverage. If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time.

Records
The telepsychology sessions shall not be recorded in any way unless agreed to in writing by mutual consent. A record of our tele session will be kept in the same way I maintain records of in-person sessions in accordance with my policies.

Informed Consent
This agreement is intended as a supplement to the informed consent form that we agreed to at the outset of our clinical work together and does not amend any of the terms of that agreement. Your signature below indicates agreement with its terms and conditions.

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New Hippa

Carlos Durana, Ph.D., M.Ac.

4915 St. Elmo Ave., Suite 504 - Room 7C
Bethesda, MD 20814
301-654-0800
2265 Cedar Cove Court
Reston, VA 20191
703-408-4965
703-620-0420 (FAX)

To my clients: I am required to give this notice to you under the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). This notice describes how medical/psychological information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.

This notice will tell you about the ways in which I may use and disclose health information about you. I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. This notice applies to all the records of your care produced by my practice. I need this record to provide you with superior care and to comply with certain legal requirements. I will also describe your rights to the health information I keep about you and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures, I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all the ways in which I am permitted to use and disclose information will fall within one of the categories.

Some uses and disclosures require your authorization:

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure category will be listed. However, all the ways I am permitted to use and disclose information will fall within one of the categories.

I may use or disclose PHI without your consent or authorization in the following situations:

Certain Uses and Disclosures Require You to Have the Opportunity to Object:

Disclosures to family, friends, or others. I may provide your PHI to a family member or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

Acknowledgement of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

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Patient COVID Questionnaire

Carlos Durana, Ph.D., M.Ac.

4915 St. Elmo Ave., Suite 504 - Room 7C
Bethesda, MD 20814
301-654-0800
2265 Cedar Cove Court
Reston, VA 20191
703-408-4965
703-620-0420 (FAX)

Dear Patients,
This document contains important information about in-person services in light of the public health crisis.
Your Responsibility to Minimize Your Exposure:
To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, and our families, and other patients) safer from exposure, and sickness.

*You will keep your appointment only if symptom free. Do you have any of the following? (Fever, Cough, Shortness of Breath, Flu-like symptoms etc.) *
*Have you had contact with any confirmed COVID-19 positive people?
*Have you traveled to any foreign country? *
*Have you traveled domestically? *
In addition, please initial that you are in agreement with the following:
I may change the above precautions if additional local, state, or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.

My practice has taken steps to reduce the risk of spreading the virus within the office. Please let me know if you have questions about these efforts. These include the wearing of masks by both myself and my patient. Masks will be provided if needed. If you arrive by car, please wait in your car until I call you. Appointments will be staggered to ensure limited exposure to others.

If you have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details of the reason(s) for our visits. By signing this form, you are agreeing that I may do so without an additional signed release.

This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together.
Your signature below shows that you agree to these terms and conditions.

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ASSESSING OUR RELATIONSHIP QUESTIONNAIRE:

Carlos Durana, Ph.D., M.Ac.

4915 St. Elmo Ave., Suite 504 - Room 7C
Bethesda, MD 20814
301-654-0800
2265 Cedar Cove Court
Reston, VA 20191
703-408-4965
703-620-0420 (FAX)
Offering Couples Counseling, Couples Therapy, Marriage Counseling, and Marriage Therapy in Reston, VA. and Bethesda, MD.
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Managing The Relationship Questionnaire

Carlos Durana, Ph.D., M.Ac.

4915 St. Elmo Ave., Suite 504 - Room 7C
Bethesda, MD 20814
301-654-0800
2265 Cedar Cove Court
Reston, VA 20191
703-408-4965
703-620-0420 (FAX)
Offering Couples Therapy, Couples Counseling, Marriage Therapy and Marriage Counseling in Reston, VA. and Bethesda, MD.
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Problem Diagnosis Questionnaire

Carlos Durana, Ph.D., M.Ac.

4915 St. Elmo Ave., Suite 504 - Room 7C
Bethesda, MD 20814
301-654-0800
2265 Cedar Cove Court
Reston, VA 20191
703-408-4965
703-620-0420 (FAX)
Offering Couples Therapy, Couples Counseling, Marriage Counseling and Marriage Therapy in Reston, VA. and Bethesda, MD.
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Problem Diagnostic Questionnaire Individual

Carlos Durana, Ph.D., M.Ac.

4915 St. Elmo Ave., Suite 504 - Room 7C
Bethesda, MD 20814
301-654-0800
2265 Cedar Cove Court
Reston, VA 20191
703-408-4965
703-620-0420 (FAX)
Dr. Carlos Durana offers Individual Counseling and Psychotherapy, Couples Therapy, Couples Counseling, Marriage Counseling, and Marriage Therapy in Reston, VA and Bethesda, MD.
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Therapy Consent Form

Carlos Durana, Ph.D., M.Ac.

4915 St. Elmo Ave., Suite 504 - Room 7C
Bethesda, MD 20814
301-654-0800
2265 Cedar Cove Court
Reston, VA 20191
703-408-4965
703-620-0420 (FAX)
The Nature of Psychotherapy:

Therapy works best when you are an active partner in the process, so please know that I welcome your feedback or questions about our work at any time. Participating in therapy may result in benefits, including, but not limited to: improved interpersonal relationships; reduced stress and anxiety; better communication with loved ones; increased capacity for intimacy; a decrease in negative thoughts and/or self-sabotaging behaviors; increased comfort in social, work and family settings; increased self-confidence and self-acceptance; greater ability to experience life more fully; more balance in life; and deeper self-awareness. Such benefits may require substantial effort on your part, including active participation in the therapeutic process, honesty, and a willingness to change feelings, thoughts and behaviors as needed. There is no guarantee that therapy will yield any or all of the benefits listed above. The counseling process involves responsibility and commitment on the part of the clinician and on the part of the client. You will receive the most benefit from counseling if you attend your sessions regularly and participate actively in the counseling process. Please arrive on time for your appointments and make arrangements to stay for the duration of the session.

Participating in therapy may involve discomfort, including discussing difficult feelings and experiences, and may evoke strong emotions, including anger, sadness, and fear. During the therapeutic process, many clients find that they may initially feel worse before they feel better. This is generally a normal course of events. Personal growth and change may be easy and swift at times while slow or frustrating at other times. You may also at times feel conflicted about attending sessions. If this is the case, I urge you to bring up your concerns so that we can address them. The process of therapy may sometimes result in unanticipated outcomes, such as changes in personal or career relationships and goals. Please be aware that any decisions about your relationships, personal life, or work life are your responsibility.

Confidentiality:
Psychotherapy is designed to be a safe place for you to talk about any personal issues you choose to explore. Please know that whatever we discuss in psychotherapy is legally held as private and is generally confidential. This means that I will not divulge anything you tell me to anyone except under one of the following conditions:

For example, I have a duty to report any suspected cases of child abuse and/or neglect to the Virginia Child Protective Services and to report any suspected cases of the abuse, neglect, and/or exploitation of an adult to Virginia Adult Protective Services. I also have a duty to report when there is a reasonable suspicion that a client poses a threat to herself/himself or to others.

Additionally, if you become involved in a lawsuit, especially a lawsuit in which you or your spouse are seeking a divorce or in which the care and custody of your children is at issue, I may have to disclose information and/or health records pertaining to you. Unless you give me written consent to release any requested information or health records, I will only disclose such information or health records in accordance with a lawful Subpoena duces tecum or Witness Subpoena.

Further, a federal law known as The Patriot Act (2001) requires therapists and others in certain circumstances to provide the FBI with client records and other items, and can prohibit the therapist from disclosing to the client that the FBI sought or obtained the items under the Act.

If you are seeing me for couple’s or family therapy, I consider your relationship to be the client. During the course of our work, I may see one of you individually for one or more sessions or for part of a session. All sessions should be seen as part of the work that I am doing with the couple or the family unless otherwise indicated.

Finally, from time to time I consult with other licensed, experienced therapists on how I can better help my client. These consultants are bound by the same laws of confidentiality outlined here. However, when this is done, no personal identifiers such as names are used.

Fees and cancellation policy:

Therapy sessions are normally 50 minutes long. Fees are payable each session by check, cash, or credit card (MasterCard/Visa). Longer sessions are pro-rated at the per hour rate. When we schedule an appointment, that time is reserved entirely for you. Therefore, if you need to cancel an appointment, please let me know at least 24 hours in advance; otherwise, I will have to charge you for the missed session since I will not be able to fill the appointment time on short notice.

Also, there is no charge for brief phone calls (up to five minutes), but longer phone sessions with you or with any professionals or others you ask me to speak with on your behalf are subject to a charge based on the length of the call. My hourly rate for these calls will be $150.00.

If you become involved in a lawsuit and you request or require me to testify on your behalf, or I am required to respond to requests for information and/or health records, you will be charged for my time. My hourly rate for any time spent in Court will be $250.00, and my hourly rate for my travel time to and from Court will be $140.00. Any preparation time, including time spent responding to requests for information and/or health records, will be billed at $150.00 per hour. It is not my preference to become involved with any legal actions involving my client.

Therapist availability and emergency procedures: You can leave messages for me at any time. I normally return phone calls within 1 business day. In a life-threatening emergency, always call 911 immediately.

Completion of Therapy:

The length of your therapy depends on the specifics of your situation and the progress we achieve. As we approach the completion of your goals, I will discuss with you a plan for ending therapy. If during therapy you come to feel that the issues for which you are seeking therapy are not being satisfactorily addressed and you wish to see another therapist, I will offer you referrals to other therapists to assist in a smooth transition if you desire. If it becomes clear to me that you are not benefiting from our work together, I am ethically bound to stop treating you, and I will provide you with referrals to other sources for therapy. You may discontinue therapy at any time. Should you choose to end your therapy, I will generally recommend that we meet

for at least one final visit to facilitate a positive termination experience and give us an opportunity to reflect on the work that has been done.

If you have any questions about the above, please ask me. Otherwise, please sign below. By signing, you acknowledge that you have reviewed this document and fully understand everything in it, you have had any questions with regard to this document answered by me and you consent to participate in psychotherapy with me.

Note: If you have printed out this form and are faxing it back or scanning it and emailing it back, please sign your name on the first line below. If you are filling out this form on an electronic device, please type your name in both the “sign name” and “print name” lines. Doing so will serve as your electronic signature to indicate that you understand and agree to the above.

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Couple Informed Consent Form

Carlos Durana, Ph.D., M.Ac.

4915 St. Elmo Ave., Suite 504 - Room 7C
Bethesda, MD 20814
301-654-0800
2265 Cedar Cove Court
Reston, VA 20191
703-408-4965
703-620-0420 (FAX)

We understand that couple’s therapy begins with an evaluation of our relationship, past and present. While Dr. Durana is deciding whether he is the appropriate therapist for us, we will decide whether we wish to begin couple’s therapy with him. We understand that because of the commitment of time and money, plus the potential impact on us and others (see below), it is important to make an informed choice for a couple’s therapist.

We have read and understood the potential limits of confidentiality, including those imposed by Dr. Durana’s policies and by state law, and we have received a copy to keep.

I understand that it is Dr. Durana’s role to provide therapeutic services so that we might feel better and/or improve our functioning, especially as it relates to our family. Dr. Durana’s role is not intended to gather information for the courts or to make judgments related to our family.

Therefore, we each agree that we will not call upon Dr. Durana to provide treatment records or to testify in a future divorce or custody action. We understand that courts can appoint professionals who have had no prior contact with our family to conduct independent evaluations and make recommendations to the court.

We understand that it is Dr. Durana’s policy to have no court involvement in a case in which he provides couple’s counseling because doing so could harm our professional relationship and the ability to achieve our goals. Our goals include resolving personal concerns so that we might preserve our marriage and/or be better parents. Since we need to speak freely in order for our sessions to be effective, we agree never to ask Dr. Durana to testify or have his records of our treatment disclosed in the context of a court proceeding.

By signing this form, we both agree not to seek to use any of Dr. Duran’s therapeutic intervention records or seek his testimony in any future court proceedings.
We understand all policies as described on the PATIENT INFORMATION sheet and accept them as conditions for entering into couple’s therapy with Dr. Durana.

We have been given the opportunity to ask questions and discuss confidentiality and disclosure policies with Dr. Durana. We understand that while working as a couple anything either of us might say to Dr. Durana individually, whether by phone or in an individual session, will be held confidential and will not be shared with our spouse/partner without the individual’s consent.

We agree to share responsibility with Dr. Durana for the therapy process, including goal setting and the termination of therapy. By signing this form, we acknowledge that we both understand that working toward change may involve experiencing difficult and intense feelings, some of which may be painful, in order to reach therapy goals. We understand that the changes one or both of us make may have an impact on our partner and on others around us. We accept that such changes can have both positive and negative effects and agree to clarify and evaluate the potential effects of changes before undertaking them.

Dr. Durana has further explained that his therapeutic focus in couple’s therapy is on preserving and enhancing the relationship rather than a focus on individual happiness. If remaining together is harmful to one or both partners, the focus will be on facilitating an amicable separation.

By signing below, we agree to accept mental health services from Dr. Durana and accept full responsibility for payment for such services.

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Adolescent Informed Consent Form

Carlos Durana, Ph.D., M.Ac.

4915 St. Elmo Ave., Suite 504 - Room 7C
Bethesda, MD 20814
301-654-0800
2265 Cedar Cove Court
Reston, VA 20191
703-408-4965
703-620-0420 (FAX)

The purpose of meeting with a counselor or therapist is to get help with problems in your life that are bothering you or that are keeping you from being successful in important areas of your life. You may be here because you wanted to talk to a counselor or therapist about these problems. Or, you may be here because your parent, guardian, doctor or teacher had concerns about you. When we meet, we will discuss these problems. I will ask questions, listen to you and suggest a plan for improving these problems. It is important that you feel comfortable talking to me about the issues that are bothering you. Sometimes these issues will include things you don’t want your parents or guardians to know about. For most people, knowing that what they say will be kept private helps them feel more comfortable and have more trust in their counselor or therapist. Privacy, also called confidentiality, is an important and necessary part of good counseling.

As a general rule, I will keep the information you share with me in our sessions confidential, unless I have your written consent to disclose certain information. There are, however, important exceptions to this rule that are important for you to understand before you share personal information with me in a therapy session. In some situations, I am required by law or by the guidelines of my profession to disclose information whether or not I have your permission. I have listed these situations below.

You tell me you plan to cause serious harm or death to yourself, and I believe you have the intent and ability to carry out a threat in the very near future. I must take steps to inform a parent or guardian of what you have told me and how serious I believe this threat to be. I must make sure that you are protected from harming yourself.

You tell me you plan to cause serious harm or death to someone else who can be identified, and I believe you have the intent and ability to carry out this threat in the very near future. In this situation, I must inform your parent or guardian, and I must inform the person who you intend to harm.

You are doing things that could cause serious harm to you or someone else, even if you do not intend to harm yourself or another person. In these situations, I will need to use my professional judgment to decide whether a parent or guardian should be informed.

You tell me you are being abused-physically, sexually or emotionally – or that you have been abused in the past. In this situation, I am required by law to report the abuse to the Department of Social Services.

You are involved in a court case and a request is made for information about your counseling or therapy. If this happens, I will not disclose information without your written agreement unless the court requires me to. I will do all I can within the law to protect your confidentiality, and if I am required to disclose information to the court, I will inform you that this is happening.

Except for situations such as those mentioned above, I will not tell your parent or guardian specific things you share with me in our private therapy sessions. This includes activities and behavior that your parent or guardian would not approve of – or would be upset by – but that do not put you at risk of serious and immediate harm. However, if your risk-taking behavior becomes more serious, then I will need to use my professional judgment to decide whether you are in serious and immediate danger of being harmed. If I feel that you are in such danger, I will communicate this information to your parent or guardian.

Example: If you tell me that you tried alcohol at a few parties, I would keep this information confidential. If you tell me that you are drinking and driving or that you are a passenger in a car with a driver who is drunk, I would not keep this information confidential from your parent or guardian. If you tell me, or if I believe based on things you’ve told me, that you are addicted to alcohol, I would not keep this information confidential.

Example: if you tell me that you are having protected sex with a boyfriend or girlfriend, I would keep this information confidential. If you tell me that, on several occasions, you have engaged in unprotected sex with people you do not know or in unsafe situations, I will not keep this information confidential. You can always ask me questions about the types of information I would disclose.

, would you tell their parents?”

Even if I have agreed to keep information confidential – to not tell your parent or guardian – I may believe that it is important for them to know what is going on in your life. In these situations, I will encourage you to tell your parent or guardian and I will help you find the best way to tell them. Also, when meeting with your parent or guardian, I may sometimes describe problems in general terms, without using specifics, in order to help them know how to be more helpful to you.

[You should also know that, by law in Virginia, your parent or guardian has the right to see any written records I keep about our sessions. It is extremely rare that a parent or guardian would ever request to look at these records.]

School: I will not share any information with your school unless I have your permission and permission from your parent or guardian. Sometimes I may request to speak to someone at your school to find out how things are going for you. Also, it may be helpful in some situations for me to give suggestions to your teacher or counselor at school. If I want to contact your school, or if someone at your school wants to contact me, I will discuss it with you and ask for your written permission. A very unlikely situation might come up in which I do not have your permission but both I and your parent or guardian believe that it is very important for me to be able to share certain information with someone at your school. In this situation, I will use my professional judgment to decide whether to share any information.

Doctors: Sometimes your doctor and I may need to work together; for example, if you need to take medication in addition to seeing a counselor or therapist. I will get your written permission and permission from your parent or guardian in advance to share information with your doctor. The only time I will share information with your doctor even if I don’t have your permission is if you are doing something that puts you at risk for serious and immediate physical/medical harm.

Signing below indicates that you have reviewed the policies described above and understand the limits to confidentiality. If you have any questions as we progress with therapy, you can ask your therapist at any time.

Check boxes and sign below indicating your agreement to respect your adolescent’s privacy:

/_/ I will refrain from requesting detailed information about individual therapy sessions with my child. I understand that I will be provided with periodic updates about general progress, and/or may be asked to participate in therapy sessions as needed.

/_/ Although I have the legal right to request written records/session notes since my child is a minor, I agree NOT to request these periodic records in order to respect the confidentiality of my adolescent’s treatment.

/_/ I understand that I will be informed about situations that could endanger my child. I know this decision to breach confidentiality in these circumstances is up to the therapist’s professional judgment and may sometimes be made in confidential consultation with her consultant/supervisor.

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Coaching Agreement

Carlos Durana, Ph.D., M.Ac.

4915 St. Elmo Ave., Suite 504 - Room 7C
Bethesda, MD 20814
301-654-0800
2265 Cedar Cove Court
Reston, VA 20191
703-408-4965
703-620-0420 (FAX)

(“CLIENT”). Please read this carefully and indicate your agreement by signing at the bottom of the page. Let me know if you have any questions or concerns.

Coach has positive expectations for a coaching relationship that helps Client create the life he/she wants to live. The opportunity for Client’s success increases considerably because of Client’s and Coach’s relationship and the commitment involved from the two.

Coaching is a structure that facilitates the process of personal and professional development. Coaching may address life balance and quality of life, health and wellbeing, personal projects or job performance satisfaction. Client and Coach agree that the coaching relationship will be designed together.

Coaching is for persons who are psychologically healthy and who want to make changes to empower themselves. Coaching is not counseling or therapy.

Client and Coach acknowledge that Client wants to make progress and change in his/her life. Coaching is a process. Many people create change for themselves in a short time. However, to refine and sustain change takes several months. Progress and change are specific to each individual. Although not binding, Client and Coach commit to working together for an initial three-month period. This allows the necessary time to develop objectives and progress through obstacles and successes. If the coaching is not working as Client wishes, Client should inform Coach immediately so that steps can be taken to correct any problems.

Coaching sessions are conducted in person or by telephone, unless otherwise arranged. After the initial three-month period, coaching sessions are arranged as needed. Sessions are started and concluded on time. If Client is late for a session, the time will not be extended after the allocated time. Fees are paid at the time of the appointment. For telephone sessions, Client will pay for telephone charges. To reschedule a session, please allow at least 24 hours’ notice, or the session fee will be charged. Coach wants to have a coaching relationship that is honest, direct, open and trusting. Telephone or email communication may pose extra challenges since we cannot see facial expressions, body language, etc. Therefore, Client and Coach each agree to promptly ask for clarification if there is a misunderstanding and we are using either of these methods of communication.

In between coaching sessions, Client may feel free to email or call Coach. Calls made between the scheduled calls are permissible. Coach will conduct calls of five minutes or less free of charge, but Client will be charged accordingly for longer calls. There is no commitment beyond month to month, but Client is asked to give Coach a week’s notice if he/she thinks he/she will be ending our Coaching together.

The coaching relationship is built on trust. Coach agrees to keep all information and conversations with Client private and confidential. No personal information expressed by Client will be shared with anyone except with the written permission of Client or by a court order. Confidentiality is followed to the fullest extent of the law and so long as Coach does not fear for Client’s or another’s safety.

Coach cannot guarantee results. Client’s intentions, choices, courage and determination to take actions in his/her life will create the results Client desires.

Coach will fully collaborate with Client to identify and achieve Client’s personal and professional goals. If issues come up for Client that should be handled by a physician, therapist or other health professional, Coach will recommend that Client attend to his/her health by contacting the appropriate professional.

Coach will bring support, understanding, and a belief in Client and Client’s commitment to his/her own success. Part of Coach’s job is to challenge Client, offer different perspectives, make suggestions (including assigning homework) and acknowledge Client’s successes.

Client is committed and motivated to take action on his/her personal and professional goals. Client acknowledges that only his/her intentional full participation will lead to success. Client realizes that the process of change can involve feelings of discomfort and frustration.

Client accepts full responsibility for himself/herself and the actions he/she takes that might result from coaching. Client acknowledges that he/she is healthy enough to engage in coaching.

Client has read the Coaching Agreement and agrees with its terms.
Coach has read the Coaching Agreement and agrees with its terms.
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Life History Questionnaire

Carlos Durana, Ph.D., M.Ac.

4915 St. Elmo Ave., Suite 504 - Room 7C
Bethesda, MD 20814
301-654-0800
2265 Cedar Cove Court
Reston, VA 20191
703-408-4965
703-620-0420 (FAX)

The purpose of this questionnaire is to get a complete picture of your life history and family background. In therapy, we are concerned with issues that impact on you, your relationships, and your family from many sources. Among those sources are (a) your family of origin, that is your parents and grandparents; (b) your physical health; (c) your life history; and (d) things that are influencing you right now. By asking you about these things in questionnaire form, we can save a great deal of valuable therapy interview time. Therefore, answering these routine questions as fully and as accurately as you can will make it possible for us to get to work on the things that concern you much more quickly.

All case records are strictly confidential. NO OUTSIDER IS PERMITTED TO SEE YOUR CASE RECORD WITHOUT YOUR PERMISSION IN WRITING.

If you have any questions about this questionnaire, please feel free to ask at any time. If you do not wish to answer a question, you may write “I do not wish to answer.”

How did you hear about Dr. Durana? (circle those that apply)
Referral Web Google Listing Other

Current Relationship Status (check one)
Remarried:
On the scale below, please indicate how upsetting your problem(s) is/are right now:
Siblings:
Does or did your mother have (check all that apply):
Did or does any other member of your family have problems with (check all that apply):
Your religion:
Your education:
Check any of the following that applied during your childhood or adolescence:
Has any relative attempted or committed suicide?
Has any relative had serious problems with the law?
Your Personal History:
Do you now have or have you ever had (check all that apply):
Have you ever been hospitalized for psychological problems?
Do you have a family physician?
Have you ever attempted suicide?
Does your present work satisfy you?
Check any of the following behaviors that apply to you:
Menstrual History:
Are your periods regular?
Do you have pain?
Does your period affect your mood?
Your Current Family/Your Family of Procreation Relationship:
Sexual Relationships:
Was sex discussed in your home?
Have you ever experienced any anxiety or guilty feelings arising out of sex or masturbation?
Is your present sex life satisfactory?
Children and Family:
Stress:

Check any of the following which apply and indicate the family member involved such as partner, child, father, mother, brother, sister, yourself and so on:

Event Family Member(s) Involved
Systems Outside of Your Family:
Has your Bishop, Priest or Clergy made a special effort to talk to you about your behavior or the behavior of a member of your family?
Have the police or other social agencies interfered in your family?
Have there been any other outside disturbances to your family?
Friendships:
Do you make friends easily?
Do you keep them?
Rate the degree to which you generally feel comfortable and relaxed in social situations:
Expectations regarding therapy:
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INTAKE FORM – I

Carlos Durana, Ph.D., M.Ac.

4915 St. Elmo Ave., Suite 504 - Room 7C
Bethesda, MD 20814
301-654-0800
2265 Cedar Cove Court
Reston, VA 20191
703-408-4965
703-620-0420 (FAX)

New Client Intake Form (Please print or write clearly)

If applicable, click a number to indicate your level of difficulty.
Are any other practitioners treating this condition? Y / N
Do you or have you ever had (circle and mark year):
Have you ever taken adrenal corticosteroids (cortisone, prednisone, etc.)? Y / N
Family Medical History
Musculoskeletal
Gastrointestinal
Cardiovascular
Skin and Hair
Eyes
Sleep
Urinary and Genital
Pregnancy and Gynecology
Respiratory
Head, Ears, Nose, Mouth, Throat and Neurological
General
Emotional
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INTAKE FORM – II

Carlos Durana, Ph.D., MA,

If applicable, circle a number to indicate your level of difficulty.
Are any other practitioners treating this condition?
Do you or have you ever had (circle and mark year):
Have you ever taken adrenal corticosteroids (cortisone, prednisone, etc.)? Y / N
Family Medical History
Musculoskeletal
Gastrointestinal
Cardiovascular
Skin and Hair
Eyes
Sleep
Urinary and Genital
Pregnancy and Gynecology
Respiratory
Head, Ears, Nose, Mouth, Throat and Neurological
General
Emotional

About A Caring Approach

Dr. Durana draws on a wide variety of successful psychotherapeutic methods when working with patients. A combination of holistic therapeutic services may be needed to confront the challenges in your life, and A Caring Approach will help you create your own wellness strategy using methods to manage your progress.

Our Locations

4915 St. Elmo Ave.,
Suite 504 - Room 7c
Bethesda, MD 20814
(301) 654-0100

1875 Campus Commons Dr.
Suite 210 - Room 11B
Reston, Virginia, 20191
(703) 775-1074

1625 K Street, NW,
Suite 375C
Washington, DC 20006
(202) 601-3538

2265 Cedar Cove Court
Reston, VA 20191
(703) 884-8810