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HEBE ESTRELLA-SCHULTZ MD Diplomate of the American Board

HEBE ESTRELLA-SCHULTZ MD Diplomate of the American Board 2025

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The document is an application for service and consent for treatment of minors by Dr. Hebe Estrella-Schultz, a psychiatrist. It outlines the consent process for evaluating and treating a child, including financial responsibilities, confidentiality of records, and potential charges for missed appointments or additional services. It also includes assessment scales for ADHD and anxiety disorders to be filled out by parents, as well as questionnaires related to mood disorders.

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Click ‘Get Form’ to open the HEBE ESTRELLA-SCHULTZ MD Diplomate of the American Board document in our editor.
Begin by filling out the consent section at the top, where you will enter your name and your child's name. This section is crucial for authorizing treatment.
Proceed to the Payments/Assignment of Benefits section. Here, ensure you accurately assign medical benefits to Dr. Estrella-Schultz by providing necessary insurance details.
In the next sections, carefully read through each statement regarding financial responsibility and cancellation policies. Make sure to check any boxes that apply to your situation.
Complete the NICHQ Vanderbilt Assessment Scale by rating your child's behaviors over the past six months. Use the provided scale from 'Never' to 'Very Often' for accurate responses.
Finally, review all entries for accuracy before signing and dating at the bottom of the form. This ensures that all information is correct and complete.

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