INTRODUCTION

Our mission is to be Charlotte's premier provider of the most comprehensive array of biofeedback services with the best-trained, most caring professionals in the business. The purpose of this informed consent is to provide written information regarding the risks, benefits, and alternatives of the services described below and to communicate important information about our professional services and business policies. Your signature is your acknowledgement that you understand the type of service you can expect, and what is expected of you. We also want to ensure that you are aware of our practice scope and limitations. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions, please ask prior to signing this consent form. Your initial of each section indicates that you have read that portion and agree.

DESCRIPTION OF SERVICES

Biofeedback is a training method used to help improve stress-related or nervous system regulation issues related to symptoms such as chronic stress, executive function, or post-trauma syndromes affecting the autonomic nervous system. Common complaints of those seeking our services include, but are not limited to anxiety, depression, insomnia, chronic pain, migraine, fibromyalgia, chronic fatigue, tension headaches, gastrointestinal difficulties, sensory sensitivities, memory issues, focus, concentration, impulsivity, and deficits of executive function.

It is important to understand that Biofeedback is not a medical service and is not the same as psychotherapy. It is not a substitute for the benefits of medication and psychotherapy and you are encouraged to explore such options in tandem with biofeedback training. In many cases, the goal of biofeedback therapy is to support reducing the need for medication and to promote symptom alleviation. However, presciptions are to be determined by your physician, specialist, or mental health provider, and we are happy to serve as a resource for them. Before altering dosages or discontinuing prescription medications already in use, you should first consult with your prescribing physician, regardless of symptom alleviation as a result of biofeedback. Any changes you do make need to be reported to us, including new medications, changing medications, and dosage changes. 

 

 

POTENTIAL RISKS AND BENEFITS

The best way to conceptualize Biofeedback is as an educational or coaching service by a highly-trained practitioner who is familiar with the mind-body-emotion mechanisms relating to attention, regulatory systems, stress, and pain. Committing oneself to personal change and self-regulation can be an intensive, interpersonally focused process. Individualized responses are to be expected.

Biofeedback is generally regarded as non-invasive and safe with minimal potential for adverse responses. There is a broad array of research studies published on the effective use of biofeedback, and to date, no significant injuries have been reported. Any adverse effects are rare, minor, and short-term, dissipating within a few hours, but if experienced they should be reported to the practitioner immediately or before the start of the next planned session so that we can make adjustments. In particular, headache, negative sleep differences, nightmare, agitation, irritability, or moodiness would indicate a change in training is necessary. Please do not delay in notifying us for anything you regard as new or different in a negative way.

The benefits of biofeedback training, in addition to symptom relief, usually include improved self-awareness, and increased awareness of psychological, physiological, and lifestyle contributors to your presenting symptoms. Scientific investigation is ongoing to determine the mechanism by which obvious self-regulatory benefits are achieved. The FDA finding is that biofeedback training facilitates nervous system calming, self-regulation and relaxation. Most clients report better sleep, increased energy level, enhanced calmness, enhanced focus, improved attention and concentration, improvement to memory and immediate recall, reduced emotional reactivity, awareness of dreaming, and physiologic relaxation.

You are responsible to keep us informed of any training effects you may be having that are new or different to you, including symptom intensification. Nothing we do together should create discomfort, and it is important for you to report any such issues immediately to your licensed physician or therapist, as well as to our biofeedback staff. In the event of any reported discomfort, we will make every effort to be supportive and provide oversight and direction, including but not limited to suspending biofeedback training, adjusting our training protocol, recommending psychotherapy, and/or recommending a referral.

Our first and foremost consideration is safety. Each training room is carefully arranged and monitored to ensure accurate readings and proper measurements.  In addition, the manufacturer of the equipment has built-in safety monitoring devices that promote safety. 

SCOPE OF PRACTICE AND OUR QUALIFICATIONS 

It is important to note that none of our clinicians offer counseling or medical advice as a part of our services, and it is beyond our stated scope of practice to provide any diagnoses. Medical and psychological diagnoses and directives must come from your doctor or counselor. Our clients often find us through referral from their licensed physicians, specialists, psychologists or counselors. We advocate for a multi-disciplinary approach wherever complex cases or chronic pain is concerned. With your permission Carolinas Biofeedback Clinic will collaborate and communicate with your referring doctor or specialist (such as Neurologist or Clinical Psychologist) to attempt to obtain the best possible outcome for you.

Melanie Berry is our Clinical Director and the owner of Carolinas Biofeedback Clinic, founded in 2008. In the field of Biofeedback, Board Certification is the highest form of credentialing and competency. She is double Board Certified: 1) as a Biofeedback Fellow from the gold-standard credentialing body, Biofeedback Certification International Alliance (BCIA), and 2) as Neurotherapist by the Natural Therapies Certification Board (NTCB). She has over 400 hours of rigorous neuroscience education and advanced skills training in qEEG acquisition, analysis, interpretation and protocol planning, which has earned her the distinction of qEEG Diplomate from the American Neurotherapy Association. 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 earning several sub-specialties: as HeartMath Interventionist expert in HRV Biofeedback, and as a specialist in Microcurrent ElectroTherapy. She is a Fellow at the American Institute of Stress. She has published research and is sought after as an expert for speaking and training engagements. She is affiliated with the top 5 associations serving this field of expertise, and participates in international listservs, with access to over 5,000 of the top practitioners world-wide.

The practitioners at Carolinas Biofeedback Clinic are highly educated, with graduate degrees and extensive training and competencies. The team has over 35 years of combined experience in Biofeedback and Neurofeedback, and all have multiple specialty certifications in addition to being Board Certified or in pursuit of Board Certification. Many have psychology backgrounds (school counseling, mental health counseling, and health psychology) or other allied profession (speech pathology). Our practitioners operate as a team to pool collective wisdom to best serve our clients. 

COLLABORATION WITH YOUR REFERRER

Since we opened our doors in 2008, we have been educating Charlotte area professionals in related fields (mental health counselors, neurologists, physicians, integrative and functional medicine doctors, psychiatrists, psychologists, physical and occupational therapists, and other alternative medicine practitioners) on Biofeedback, Neurofeedback and Neuromodulation. We have formed a strong network of professionals that collaborate with us for the best outcomes for our mutual clients.

With your permission, we offer to collaborate with your other specialists, physicians, or counselors. Our Advanced qEEG Brain Map provides insights that can be very meaningful to the treatment plans of these other practitioners.

The best way to encourage the coordinated effort on your behalf is to have your provider send us a referral (we have both an online form and a downloadable PDF form) that indicates that they would like to collaborate. Your part is to sign a release with them and us (ours is at the end of this form).

APPOINTMENTS

Your first visit will include a detailed review of your self-reported health history, an introduction to our equipment and techniques, and may include objective measures of baseline nervous system activity or our Advanced qEEG Brain Map. Assessments may be repeated at intervals along the process to objectively evaluate progress. The initial session is the time to voice your personal goals and any concerns for biofeedback training. We will customize an individualized training plan including one or any combination of our services to address your needs. Your care is our primary concern, so if for any reason you do not wish to continue after that visit or at any point in the process, we will be more than happy to provide a referral to another provider.

Our unique “team care” approach means clients may schedule with anyone on the team for any session in order to allow for maximum flexibility when booking. Our team staffs two Charlotte-area offices, with availability Monday through Saturday, including ample after-school and early evening hours. Appointment scheduling is completely automated so that making, changing or canceling appointments with at least 24 hours notice is easy. Confirmation and reminder emails are automated. It is the responsibility of the client to manage their own appointments and attendance. The service can be accessed from our website, via the Mindbody App from your mobile phone or tablet, or via an Automated Assistant via text from your smartphone. Recurring appointment times are often available if booked well in advance; Clinician calendars are typically visible 3-6 months in advance.

CANCELATION POLICY

We regard your time as very important and work very hard to make sure that we are available during flexible hours for you; to that end, we offer Saturday and after school/evening hours. We expect that you will provide us with similar courtesy with at least 24-hours notice of cancelation and/or a courtesy call if you are running late for a scheduled appointment. You will receive an email confirmation after booking and an email reminder the day before each scheduled appointment.

“Late Cancel” means the online 24-hour cancelation period has closed, in which case you will need to contact us directly at 888-317-5605. This may allow clients on a wait list the option of using your appointment time. Late Cancels are handled on a case-by-case basis. If we are able to fill your appointment time, or we elect to extend grace (on the first occurrence only), you will not be charged for the missed appointment. Subsequent late cancels will incur the session fee, unless we are able to fill your spot.

“No-show” means you did not come to a scheduled appointment, or you called to cancel at or too near the appointment time to give us adequate time to offer your spot to others; No-shows are charged at the regular session fee. Email and text reminders are designed to prevent accidental no-shows.

In the case of qEEG Brain Mapping, late cancelations or no-shows will be assessed a $200 charge.

After two consecutive missed appointments, it is our policy to initiate a conversation regarding the status of your program and your desire to continue. If it becomes necessary to terminate services with you, we will make every effort to arrange for the continuation of your care with another service provider.

PROFESSIONAL FEES

Our services are elective services. We work solely on a self-pay basis, and payment at the time of service is required.

As an additional cost savings option, we offer a 10% discount off the per-session rate if you purchase Neurofeedback or Biofeedback sessions as a package in advance.

Occasionally, our session fee may increase. Price Lock, our loyalty program, ensures that you will not experience training session fee increases during your program. The price lock does not apply to assessments, only to training sessions.

The requirements for Price Lock are that 1) you must be an active client at the time of the increase, and 2) no more than 1 year may lapse between sessions to retain your starting rate. If more than one year has passed since your last visit, your rate will convert to the current pricing. 

SESSIONS UTILIZING ZOOM FOR VIDEO CONFERENCING

Carolinas Biofeedback Clinic is committed to offering convenient options whenever possible. Those things that can be accomplished remotely will rely on video conferencing. In order to protect our client’s privacy, Carolinas Biofeedback Clinic utilizes Zoom to conduct these sessions. These are the guidelines we have in place:

• CBFC recommends the client joining their session in a safe, enclosed space where they may not be overheard, and may use headphones if desired.
• In the case of loss of contact, the following steps will be made by the clinician to resume the session:
  • Contact the client by phone or email upon disruption or loss of contact
  • Troubleshoot with client to discover source of disruption
  • Restart meeting with client, using a new meeting code if necessary
• If the clinician cannot resume the Zoom meeting due to technical issues, the client will not be charged for the appointment. However, if the clinician is able to resume the session but cannot reach the client or the client never enters the meeting room, it will be viewed as a late cancel and the client is subject to charge.

PAYMENT FOR SERVICES

Payment is expected at the time of service. We do offer an Affordable Payment Plan option through AdvanceCare. Through AdvanceCare you may qualify for interest-free financing for our service fees. You must apply on your own through the link on our website in advance of the first service you'd like included in your payment plan (it cannot be applied retroactively).

You may want to explore whether your Flexible Spending Account (FSA) and Health Spending Account (HSA) funds are eligible to use for Biofeedback.

Please be aware that we have no relationship with any insurance companies, but you may wish to seek reimbursement for services that you have paid for on your own. We will provide a formal receipt to support your efforts, upon request.

However, Medicare, Medicaid, and Tricare do not reimburse for our services. By signing this consent, you are expicitly stating you are aware that our services are not reimbursable by Medicare, Medicaid or Tricare and you agree not to seek reimbursement from any one of these for any of our services. 

 

CONFLICT RESOLUTION

You agree to bring any dispute or complaint directly to our attention without delay. Carolinas Biofeedback Clinic, LLC, agrees to make every effort to resolve any dispute or complaint swiftly.

CONFIDENTIALITY & PROFESSIONAL RECORDS

We value your privacy. It is our policy to maintain the confidentiality of your records. We require a Release Waiver from you in order to share your confidential information with others.

We do comply with any laws that require mandatory reporting of abuse, threats of harm to self, or threats of harm to others.

Our professional standards require that we keep appropriate records of the services we provide to you. From time to time, we get requests for client records. At your request or with your permission, we are willing to prepare a brief summary of progress document and/or provide color copies of existing brain map review packets. There is a fee for the preparation time needed to comply with this request.

Should you wish to transfer from our care, we will, at no charge, coordinate efforts directly with another practitioner of your choosing to provide them with everything necessary for a seamless transition of services, including a summary of methods utilized, pertinent reports or assessment results, and if requested, current EEG data files acquired within the last 30 days, provided there has been no Neurofeedback Training following that EEG acquisition. 

It is our policy not to share any outdated raw EEG data files. Any EEG data files that predate completed Neurofeedback Training sessions, or that were recordered more than 30 days ago, are considered outdated and will not be shared. Specific protocol details are proprietary and will not be shared.

CONSENT: In signing this consent, you are agreeing to abide by these policies, including but not limited to those related to payment for services. You understand that the practice has a cancelation policy, and if you fail to follow this policy, you will be charged a session fee to be paid prior to any further appointments. 

You understand that you have the right to discontinue services at any time.

Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. You have fully read and understand the risks, benefits, and alternative options available, and by signing below you willingly assume those risks. You have had an opportunity to discuss and ask questions of the staff to your complete satisfaction.

OPTIONAL RELEASE WAIVER TO SHARE INFORMATION: Your signature below authorizes our Clinical Director to speak to your designated health care providers, counselor, and/or specialists about your case.