Please read the information below so that you can provide your Informed Consent for psychological assessment and treatment services at Restore Behavioral Health, PLLC (RBH). Please discuss any questions regarding this Consent with your clinician prior to initiating services.

Psychological Services:  Services include Diagnostic Assessments, Psychological Testing, Individual, Family, Marital and Group Psychotherapy, Crisis Intervention, Professional and Organizational Consultation, Psycho educational Training/Coaching, and Didactic presentations. Psychotherapy requires active participation from the client and may involve increased awareness into emotions of sadness, anger, or anxiety.

Hours and Session Duration:  Hours of Operation are from 9:00am to 6:00pm Monday through Friday.  Saturday appointments may also be available. Therapy sessions will typically last 45 minutes, although there may be instances that require a shorter or longer visit.

Fees and Health Insurance:  RBH will verify your health plan insurance eligibility for mental health and substance abuse benefit coverage.  Most insurances are accepted. however you are responsible for services not covered by your insurance company. For evening & Saturday visits, a credit card must be kept on file for automatic Co Pay processing.  RBH is on several Health Insurance panels and accepts health insurance reimbursement under these specific Provider Agreements. The Fee-For-Service rates are listed below:

Cancellation Policy:  Patients are asked to keep their appointments, as this time has been specifically reserved for you. Please notify the office of

any need to cancel your appointment with 3 business days notice in order to avoid the cancellation fee.           

         $75 Cancellation Fee - All QEEG & Testing Appointments   

        $45 Cancellation Fee - Therapy, Test Results, NFB, HBI Appts

           *** If there are three or more cancellations, we will be unable to accommodate scheduling recurring appointments;Scheduling an appointment can be made available on a waiting list /call in basis. ***

Confidentiality:  All records will be kept confidential and will be held in accordance with the state and federal regulations regarding the confidentiality of such records and Personal Health Information. Privileged information will only be released upon the client’s written authorization. The following are exceptions to the privilege of confidentiality:

1) All situations involving abuse or neglect, or suspicion thereof, of a child or elderly person must be reported to the appropriate protective agency.   2) If there is an imminent danger of harm to self or others, information may be released to the medical and/or law enforcement personnel for the coordination of emergency care. 3) Records must be released in accordance with any court proceedings, subpoenas, qualified audits, program evaluations or investigations authorized by state or federal regulations. RBH does NOT accept court-related cases or conduct custody evaluation & can provide a referral for these cases.

Release of Information:  RBH may release information with your consent for the reasons noted on your signed HIPAA notice. RBH may be required to release information regarding your assessment and/or treatment with your insurance company pertaining to authorization or medical necessity determinations.  Clinical case information may be communicated to other health care professionals for the purposes of consultation and/or training, and such communications will be bound by the same professional and ethical guidelines regarding confidentiality.  Releasing information to another health care professional or family member for the purpose of coordination of care will take place only with your specific authorization.

Emergency/On-Call Services: In the event of an emergency after hours please call 9-1-1- or proceed to the nearest hospital.  Restore Behavioral Health does NOT offer after hour’s on-call services.

Access of Records: The laws and standards of the profession of psychology require maintenance of treatment records. Adult clients and legal guardians or minors, including managing and possessory conservators, have the right to access the record of the services provided to them or their child.  If such access is determined to be of potential harm to a client, the information will instead be summarized or shared directly with an authorized health care professional. Third Party health insurance companies may require review of medical record documentation for claims processing.

Treatment of a Minor:  Treatment of children under the age of 18 will be provided with the consent of the Parent or Legal Guardian.  For divorced parents, managing conservators are required to provide consent for treatment of the minor.  A copy of the divorce decree or court order designating conservatorship is required at the time of intake.  In some emergency situations, a minor may consent to his/her own treatment.

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