QEEG & Neurofeedback Informed Consent

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QEEG & Neurofeedback Informed ConsentRBH QEEG & NEUROFEEDBACK SERVICES INFORMED CONSENT 1/3/2022 Please read the information below so that you can provide your Informed Consent for QEEG and Neurofeedback services at Restore Behavioral Health, PLLC (“Restore”). Please discuss any questions regarding this Consent with your clinician prior to initiating services. QEEG Services: Services include a 19-channel Quantitative Encephalogram analysis and “Brain Map” report. The procedure entails wearing an electrocap with 19 sensors that record the electrical activity across different regions of the brain. Your brain wave patterns will be statistically compared to a normative database. Neurofield and traditional Neurofeedback treatment protocols will be established based on the findings of your QEEG. The client must follow a few preparation procedures and be able to sit still for an eyes open and eyes closed recording. Neurofeedback Services: Neurofeedback, or EEG biofeedback, sessions may be recommended to help the brain regulate its neurophysiological functioning. Your clinician will place one or more sensors on your scalp and your brain wave activity will be monitored. Feedback in the form of auditory “beeps” and/or visual feedback (e.g. DVD, computer game) will be provided based on the operant conditioning model of reinforcement and inhibition. Success depends on client’s regular commitment to attending sessions and practicing any recommended homework. Neurofeedback is generally considered a safe, non-invasive alternative intervention. However, some clients can experience heightened sensitivity to medications and adjustments may need to be made under your physician’s supervision. Neurofeedback is an approved relaxation method only and is considered experimental for other uses. It may alter mood, mental clarity, sleep/wake cycle, sense of calm. Memories of past trauma may be triggered. Those with a substance addiction may become allergic to the substance. Training may help facilitate neurophysiological change but is not a substitute for medication or other forms of treatment. Hours and Session Duration: Hours of Operation are from 9:00am to 6:00pm Monday through Friday. Saturday morning appointments may also be available. The QEEG will take about 1.5 hours and Neurofeedback sessions generally last 30-minutes. Fees and Managed Care: Fees are due at the time of service delivery. There is no guarantee that these services will be covered by your health insurance. The patient/Legal Guardian is responsible for submitting any claims for insurance coverage for these services. Fee-for-Service Rates: LENS2 Neurofeedback $60.00 QEEG Brain Map: $575 (Recording and Analysis) QEEG Results: Therapy benefit under insurance Traditional Neurofeedback Session: $60 [Requires QEEG] LENS2 Neurofeedback: $60.00 LENS4 Neurofeedback $80.00 LENS6 Neurofeedback $100.00 Transcranial Photobiomodulation $60.00 Neurofield Body – 30min $60.00 Neurofield Neuro – 30 Min [Requires QEEG] $95.00 Neurofield Body – 45 min $95.00 Neurofield Neuro – 45 min [Requires QEEG] $115.00 Neurofield Neuro & Body – 45 min $115.00 Cancellation Policy: Patients are asked to keep their appointments, as this time as 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 $45 cancellation fee for neurotherapy appts and $75 for QEEG appts. 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 the 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. Release of Information: Restore may release information with your consent for the reasons noted on your signed HIPAA notice. Restore be required to release information regarding your assessment and/or treatment with your insurance company in order to receive reimbursement for services provided. 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 proceed to the nearest hospital. Restore also offers 24 hour emergency on-call services for telephonic consultation. 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. Treatment of a Minor: Treatment of children under the age of 18 will be provided with the consent of the Legal Guardian. In some emergency situations, a minor may consent to his/her own treatment.
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Consent for Services:I have read and understand this statement of informed consent. I voluntarily consent to treatment at Restore Behavioral Health with the knowledge of the above conditions.
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