Informed Consent and Release Waiver

Transcription

1 1 INTRODUCTION This document contains important information about our professional services and business policies. Once you sign, it will acknowledge your understanding of the type of service you can expect, and what is expected of you. It is the most ethical way of making sure you are aware of practice scope and limitations. It is important that we discuss any questions that you may have. QUALIFICATIONS Melanie Berry is our Clinical Director. She is Board Certified in Biofedback as an Associate Fellow from the Biofeedback Certification International Alliance (BCIA) and by the Natural Therapies Certification Board (NTCB); she is also Othmer Method Certified in Neurofeedback and a Diplomate from the American Neurotherapy Association indicating advanced skills in acquisition, analysis, interpretation and protocol planning using qeeg. In the field of Biofeedback, Board Certification is the highest degree of competency. Her Masters level education in Psychology gives her valuable insight into human behavior and an appreciation for the intricacies of the mind-body interaction. She has further specialized her training, supervision, and work experience in applied psychophysiology. Advanced training has earned her several sub-specialty certificates: as a HeartMath Interventionist expert in HRV Biofeedback, and as a specialist in Microcurrent ElectroTherapy. It is important to note that she does not offer counseling or medical services and accepts cases on a referral basis from licensed physicians, specialists, psychologists or counselors because it is beyond our scope of practice to diagnose. Medical and psychological diagnoses and directives come from your doctor or counselor. Melanie advocates for a team approach from multiple disciplines wherever complex cases or chronic pain is concerned. To that end, with your permission Carolinas Biofeedback Clinic will collaborate and communicate with your referring doctor or specialist (such as Neurologist or Clinical Psychologist) to get the best possible outcome for you. Melanie is an active member of the American Neurotherapy Association (ANA), Association of Applied Psychophysiology and Biofeedback (AAPB) the Biofeedback Association of North America (BANA), the Southeast Biofeedback and Neuroscience Association (SBNA), and the EEG Institute; she is also a Fellow at the American Institute of Stress where she is a member of their Combat Stress Board. To insure that she remains current in her knowledge base and practice, she actively participates in three professional listservs. These listservs not only help her to stay current and knowledgeable, but they also offer opportunities to seek solutions in particularly unusual or complex cases. In addition, she attends annual continuing education workshops, webinars, association meetings, and seminars pertinent to our services. She is sought after as an expert for speaking and training engagements. Carolinas Biofeedback Clinic was established in 2008 and has expanded in office locations, service offerings, and staff. We currently have three locations, and our team of Neurofeedback Specialists has expanded to include Margaret-Ann Griffin (BCN, OMC), Kristyn Dunn (OMC), Ellen Bertanzetti (OMC), Gabriel Rocha (PA-C, MMSc), and Morgan Hodge (Ph.D.), all of whom have completed rigorous training in the Othmer Method of Neurofeedback, Hemodynamic Neurofeedback, and Alpha-stim, and are under direct supervision with Melanie Berry. It is common for us to collaborate on client cases and you

2 may elect to schedule with any of us for Neurofeedback sessions after your initial consultation. In order to add Advanced Brain Technologies The Listening Program to our service offerings, we hired a fully trained and certified provider: Aubrey Baughman. She is our resident expert in this specialized program and all appointments relating to The Listening Program should be scheduled with her. She is also a certified HeartMath Practitioner in HRV Biofeedback and Alpha-Stim and conducts these trainings one-on-one or in groups. Aubrey is also trained in qeeg acquisition and analysis and is pursuing certification in the Othmer Method of Neurofeedback and BCIA Board Certification in Biofeedback. INITIAL CONSULTATION and EVALUATION Melanie Berry offers a free 20-minute consult, and will conduct your initial inperson consultation, including a detailed review of your health history, an introduction to our equipment and techniques, and may include an objective measure of baseline nervous system activity or a qeeg. These measures can be repeated to evaluate progress. The initial session is also the time to voice your concerns and personal goals for Biofeedback training. Our goal is to customize an individualized training plan including one or a combination of services to address your goals. Your care is our first concern, so if for any reason you do not wish to continue after the first session or at any point thereafter, we will be more than happy to arrange a referral to another practitioner who can better meet your needs. If it becomes necessary to terminate services with you, we will make every effort to arrange for the continuation of your care. APPOINTMENTS Appointment scheduling is completely automated so that making, changing or canceling appointments with at least 24 hours notice is easy. The service can be accessed from the Appointments page on our website, or via the Mindbody App from your mobile phone or tablet. You will receive an reminder the day before your next scheduled appointment. We regard your time as very important and work very hard to make sure that we are available during workable hours for you; we offer Saturday and after school/evening hours to this end. The reciprocal expectation exists, such that you regard our time seriously and that should circumstances arise preventing your attendance on a particular visit, more than 24-hour notice of cancelation and/or a courtesy call if you are running late for a scheduled appointment is strongly encouraged and appreciated. Late Cancel means the online cancellation period has closed, in which case you will need to contact your practitioner directly at This may allow clients on a wait list the option of using your appointment time. Late Cancels are handled on a case-bycase basis. If we are able to fill your appointment time, you will not be charged, or we may elect to extend grace (on the first occurrence only). No-show mean you did not show at the appointment time, or called at or near the appointment time to cancel, which does not give us adequate time to offer your spot to others; training session No-shows are charged at the regular session fee. reminders are designed to prevent accidental no-shows. In the case of qeeg Brain Mapping, late cancelations or no-shows will be assessed a $150 charge. After two missed appointments in a row, it is our policy to initiate a conversation regarding the status of your treatment and your desire to continue. 2

3 3 PROFESSIONAL FEES We work solely on a self-pay basis, and payment at the time of service is expected. From time to time our fee structure may increase, but our commitment to existing clients is that we will never increase the session rate in effect when you began working with us. As an additional cost savings option, we offer 10% discount off the persession rate if you pre-purchase a group of 10 or more sessions at one time in advance. We do not directly process insurance, but if you would like to independently pursue reimbursement, we can provide you with paid receipts for submission to your insurance carrier. The treatment code for Biofeedback in any modality is 90901, and the assessment coding options for the qeeg Brain Map are either or Medicare Members: Carolinas Biofeedback Clinic is not eligible to enroll, nor are we eligible to opt out of Medicare. If your insurance provider is Medicare, by signing this consent, you are stating you are aware that our services are not reimbursable through Medicare and you agree not to seek reimbursement from Medicare for any of our services. DESCRIPTION OF SERVICES Biofeedback is a training method used to address stress-related or nervous system related symptoms such as chronic stress, executive function, or post-trauma syndromes affecting the autonomic nervous system. Common applications include but not limited to migraine headaches, fibromyalgia, chronic fatigue, tension headaches, insomnia, hypertension, gastrointestinal difficulties, anxiety, chronic pain and ADD/ADHD. It is not a substitute for the benefits of medication and psychotherapy and you are free to explore such options in tandem with biofeedback training. In many cases, the goal of biofeedback therapy is to reduce the need for medication and to alleviate symptoms. With your permission, we will stay in touch with your referring physician, specialist, or mental health provider to coordinate your care, especially if your goals included reduction in prescription medicines. Any changes to prescriptions already in use should be consulted first with your prescribing physician before altering dosages or discontinuing use yourself despite partial or complete symptom alleviation as a result of the biofeedback. Biofeedback is regarded as non-invasive, safe, and any adverse effects are usually transient and easily remedied if they occur. No injuries have been reported in the literature while research on the effective uses of biofeedback abound. The FDA finding is that biofeedback training effectively facilitates relaxation. It is not a medical service and is not the same as psychotherapy. Our Biofeedback services include HRV Biofeedback, Neurofeedback, The Listening Program, and MicroCurrent ElectroTherapy (Alpha-stim) and Open Focus Technique. The best way to conceptualize this service is as an educational or coaching service by a highly trained practitioner familiar with the mind-body-emotional mechanisms relating to attention, regulatory systems, stress, and pain. That said, committing oneself to personal change and self-regulation can be an intensive, interpersonally focused process. Individualized responses are to be expected. You are responsible to keep us informed of any training effects you may be having that are unusual to you, including symptom intensification, which is more typical during the earliest phases of treatment, if it occurs at all. Nothing we do together should create discomfort, and it would be important for you to

4 report anything of that order. In the event of any reported discomfort, we will make every effort to be supportive and provide oversight and direction as to proper action (which can include but not limited to suspending biofeedback treatment, recommending psychotherapy, and/or recommending a referral). You can expect timely feedback in this regard. In addition to symptom relief, benefits of biofeedback training usually include improved self-awareness and increasing awareness of psychological, physiological, and lifestyle contributors to your presenting symptoms. Our first and foremost consideration is safety. The room is carefully arranged and monitored to ensure that readings are accurate and are measuring what they should be measuring. In addition, the manufacturer of the equipment has built in safety monitoring devices that promote safety. Our commitment to our clients is to maintain the most up-todate, state of the art equipment available. CONFLICT RESOLUTION You agree to bring any dispute or complaint directly to our attention without delay., agrees to make every effort to resolve any dispute or complaint swiftly. Should you raise a concern over the services provided, and we are unable to resolve the issue directly, by signing this document you agree to seek mediation rather than legal recourse. You will submit any irresolvable dispute between us to a binding arbitration under the rules of the American Arbitration Association, and we agree to do the same. Client and clinician both waive our rights to seek remediation via the legal court system. The result of arbitration is final and binding upon both parties. CONFIDENTIALITY & PROFESSIONAL RECORDS Both by law and our professional standards require that we keep appropriate records. You are entitled to receive a copy of the records, or if you wish, a summary can be provided. Because these are professional records, they can be misinterpreted/misunderstood. If you wish to see your records, I recommend that you review them in my presence so that we can discuss what they contain. You will be charged an appropriate fee for the preparation time needed to comply with your request. In general, the confidentially of all communication between a trainee and a practitioner is protected by law, and we can only release information about our work to others with your written permission. We may find it in the trainee s best interest to discuss some cases with other consultants/supervisors who are also credentialed or licensed experts. In these consultations, we avoid revealing identifying information. The consultants are also legally bound to keep the information confidential as discussed above. However, there are some exceptions. We are mandated by law, to file a report if we suspect that a child, an elderly person, or disabled person is being abused. We are also mandated to inform authorities if we believe that a client is threatening serious bodily harm to another. We are required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization. If a trainee threatens self-harm, we may be required to seek hospitalization for the trainee, and to contact family members and/or others who can help provide protection. 4

5 CONSENT: Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. 5 Trainee Signature: Date: (If Trainee is Under 18) Parent/Guardian Signature: Date: RELEASE OF INFORMATION: Your signature below authorizes Melanie Berry to speak to my health care providers and specialists about my case. Trainee Signature: Date: (If Trainee is Under 18) Parent/Guardian Signature: Date: