CLIENT POLICIES AND PROCEDURES and INFORMED CONSENT (and this is what will appear when you register)
Fees, Payment and Cancellation
All fees are due in full at the time of service and will be collected at the start of the session. Current rates for services are posted on our website (www.neurofeedack-in.com).
Please allow 24-hours notice to reschedule or cancel your session. Your appointment time is reserved specifically for you. As a result, late cancellation or a missed appointment, unless due to a serious emergency, inclement weather or illness will result in a fee of $85.
All services will be self-pay and out of network. At this time Neurofeedback of Indiana, LLC, is not accepting insurance, however at the end of your session you can request a Superbill. This is an invoice that you can submit to your insurance carrier for out-of-network sessions and there is a possibility they may refund you a portion of the rate; this transaction is solely between you and your insurance carrier.
Payment options: Cash, Visa, MasterCard, American Express, Discover, HSA (Health Savings Account), HRA (Health Reimbursement Account) and FSA (Flexible Spending Accounts).
Services Offered and Clients Served
At Neurofeedback of Indiana, LLC, the therapeutic approach is eclectic in nature. From a wellness perspective we use client-centered, cognitive behavioral, dialectical behavioral, mindfulness-based cognitive and integrative approaches designed to be efficient, effective and ethical. We offer a warm, accepting environment that allows you to disclose challenges and find effective solutions. We serve adults ages 18 and older.
Neurofeedback of Indiana, LLC, values spirituality as an integral part of a person’s identity and recognizes this as a basis by which mental health and thriving relationships can be achieved. We are comfortable working with individuals with different spiritual backgrounds.
Confidentiality/Privileged Communication
Content of all sessions with remain confidential to persons outside the counseling process with exceptions as noted in the NOTICE OF PRIVACY PRACTICES form. Legal exceptions include but are not limited to disclosure when a client presents danger to self, client threatens to harm another person, or there is reasonable suspicion of child, dependent or elder abuse or neglect. Should an emergency arise during active treatment or following termination, in which we become concerned about your personal safety, the possibility of you injuring another person or about you receiving psychiatric care, we will do whatever we can within the limits of the law to prevent you from injuring yourself or others and to ensure that you receive proper medical care. For this purpose, we may also contact: an emergency contact (whose name you have provided), a hospital or law enforcement. Please review the NOTICE OF PRIVACY PRACTICES.
Should a family member or other significant person participate with you in treatment, a proper signed release will be obtained.
Client files are stored through an encrypted and secure online electronic medical records system that implements all required components to ensure HIPPA compliance.
Litigation Limitation
Due to the fact that therapeutic process often involves making a full disclosure with regard to matters which may be confidential in nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.) neither you (client) nor your attorney, nor anyone else acting on your behalf will call on your counselor or any employee at Neurofeedback of Indiana, LLC to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.
Contacting Us
Due to work schedule, we are often not immediately available by telephone. We will not answer the phone during a session. When we are unavailable, telephone is answered by voicemail. We will make every effort to return your call on the same day, with the exception of Sundays and holidays. If you are difficult to reach, please inform us of some times when you will be available. If you are unable to reach us and feel that you cannot wait for a return your call, contact your family physician or the nearest emergency room and ask for the counselor or psychiatrist on call. Please see our “Social Media Policy” for additional information regarding online contacts.
Social Media and Email Communication
In order to protect your confidentiality, we do not engage in online social networking with current or previous clients. Please keep in mind that communications via email over the internet are not secure. To better ensure protection of your protected health information (PHI), Neurofeedback of Indiana, LLC, will utilize a patient portal through an electronic health records system as well as a secure HIPPA compliant email application that uses secure channels to send emails. Please see our “Social Media Policy” for additional information regarding online contacts.
Emergencies
Neurofeedback of Indiana, LLC, is a private practice providing outpatient services and does not provide 24-hour emergency services. If you feel that you are in crisis, DIAL 211 or 911 or go directly to the nearest medical or psychiatric hospital.
Interruption in Treatment
Occasionally there will be interruptions in therapy due to vacation, illness or personal reasons of the therapist. For planned interruption, you will be notified as far in advance as possible. For unplanned interruption, Neurofeedback of Indiana, LLC, will notify you as soon as possible and arrange for rescheduling, or, if extended interruption will be necessary, information will be provided for a contact with whom you may meet in the event of an emergency.
Client Responsibilities
Clients agree to make a good-faith effort at participation and engagement in the therapy as an opportunity for personal growth. You may be asked to complete assignments between sessions. It is vital that you inform your counselor of other professional helping relationships that exist and both providers must be aware of your care, so that the therapeutic process is not disrupted. All care providers must agree to such an arrangement.
Minors & Parents
Clients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, we will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. We will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents of our concern. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have.
Terminating the Therapeutic Relationship
Suspension, termination or referral may be initiated by either the counselor or the client. Treatment will terminate when a) sought goals have been met; b) the client chooses to leave; or c) if a need for change in treatment relationship or specialization occurs. You have the right to terminate participation at any time for any reason, without financial obligation other than those already accrued. Termination is most often a mutual decision for the benefit of the client.
Agreement
I have read the above information completely, understand what it says, and have discussed any questions with the counselor. I realize that this is a binding agreement and I will be held to all standards mentioned above. By signing this, I agree with this document in its entirety. I consent to treatment at Neurofeedback of Indiana, LLC.
I also acknowledge that by signing below, I have read and reviewed the Notice of Privacy Practices. I understand that a copy of the Notice of Privacy Practices will be made available for me to keep if requested. [Once again, this will be when you register; you do not sign here now.]