Neurofeedback Informed Consent (Adult)
Peak Clarity Counseling Center, 2625 Redwing Rd., Suite 110, Fort Collins, CO 80526, Ph: 970-480-0707Dustin Johnson, LPC Professional Counselor License #11971, Georgia Tech 1998, Georgia State 2010
Informed Consent for Neurofeedback Training
This form outlines your rights and responsibilities for practicing Neurofeedback (NFB). Please read it carefully and raise any questions that you may have.
At Peak Clarity, we offer Neurofeedback training---also known as EEG (brain wave) Biofeedback training---- to improve brain function and reduce negative symptoms such as insomnia, depression, headaches, anxiety, attention problems, focus and learning problems. These types of conditions are generally thought to be associated with irregular brain wave activity. There is clinical and research evidence to suggest neurofeedback training as a viable training approach for many conditions (such as Chronic Pain, memory issues and fatigue).
Neurofeedback training may be taken by children and adults. We provide specific training protocols after collecting a baseline qEEG brain map assessing qualities such as magnitude of brain wave patterns, dominant frequencies and asymmetry. The brain mapping process is a recording of the electrical potentials produced by the brain itself and transmitted through the bony skull and picked up by sensors on the scalp. A brain map is similar to making a video of brain wave patterns. No stimulation is applied to the head during a brain map. Sensors are applied to standard and specific locations, and the activity that is picked up by the sensors is analyzed and compared to peers of the same age and gender. The goal of neurofeedback training is to improve symptoms related to brain function.
The neurofeedback therapy offered by this practice may include photic stimulation, or entrainment of the brain using lights within glasses. Photic stimulation is also known as visual entrainment; photic training has been found to temporarily assist the brain in finding a more normal pattern (at least, while the lights are flashing). In combination with neurofeedback training, photic stimulation may yield improvement in symptoms more quickly than neurofeedback alone. There are situations where photic stimulation is not called for, and therefore, may not be used with a client. Conditions which preclude the use of photic stimulation may include, (but are not limited to) diagnosis of, or previous, epilepsy, seizures, open head injury, PTSD, cardiovascular conditions such as stroke or TIA, use of psychoactive medications, and sensitivities to lights or flashing lights.
Our staff has education, training and experience in neurofeedback and in EEG technology. Neurofeedback training may be recommended by a doctor or other healthcare practitioner on the basis of possible efficacy for a specific condition or conditions. Scientific investigation is ongoing to determine the mechanism by which improvements occur through the application of neurofeedback training. Current research shows that neurofeedback provides a positive learning situation for the brain which may be transferrable to everyday life. EEG neurofeedback is considered by many to be an experimental treatment at this time. At Peak Clarity, we use standardized methods to determine the proper training program, and to measure progress during and after training. Because neurofeedback is considered an experimental approach, we require that clients and/or parental informed consent be obtained prior to training.
We ask that you read and understand this information and decide if you are willing to accept the risks involved before agreeing to undergo training. We are not offering medical advice in this Consent, rather, this form contains information collected from several sources and is intended to educate and inform you regarding the theory and purpose of brain mapping, neurofeedback training, along with necessary precautions. Neurofeedback training has been the subject of more than 30 years of research and clinical study. The training appears to be harmless as far as is known at present and no injuries have been reported in a review of research literature. Technically, neurofeedback does not physically do anything to you, or your child. No electrical stimulation is applied. It is not a treatment; rather, it is a training modality. The instruments used to record and measure brain waves are similar to a thermometer or EKG (as is used to measure electrical activity as generated from the heart). While we have received extensive training and are certified to provide EEG biofeedback training, we do not make any representation concerning the safety or effectiveness of the training. Clients should continue ongoing medical and/or psychological therapies previously prescribed until otherwise advised by their physicians.
We do not claim that you (or your child, if signing on behalf of your child) will improve from the training. However, results indicate that more than 80% of clients improve on at least one test scale, and more than half improve on three out of four scales. A few clients who seem to get better at first, may find that the improvement gained does not last after the training ends. Conditions such as high fever, head or neck injury, infection, or chronic stress or medical issues may impact capacity of the brain to train, and the ability of the brain to retain learning gained during neurofeedback. Such clients may benefit from further follow-up sessions, additional medical or healthcare consultation by a qualified practitioner. Some individuals may not experience any initial noticeable effect from the training. Our staff is always happy to discuss client progress. Other methods may also be effective for you, and your child. We will be happy to provide information about such services. For example, counseling may be helpful in integrating gains or new insights resulting from neurofeedback. If appropriate, a referral may be made in this regard.
By signing below, you acknowledge that you have read, and understand the information contained on these two pages
titled “Informed Consent for Neurofeedback Training”. When you agree to participate in this program, if for any reason you believe it is not in you or your child’s best interest to continue training, you (or your child) are not obligated to complete the training. This means that you may discontinue participation at any time.
Client/Patient Rights:
Everything discussed in our sessions is confidential with a few exceptions:
Client/patient Responsibilities:
Records include copies of signed forms, dates of sessions, treatment plan, brief progress notes, copies of correspondence, and verification of any other contacts made. Your records are safely and confidentially stored electronically. Your records will be treated in a manner consistent with HIPPA guidelines. You have been provided a copy of the guidelines. Any request for release of this information will need your approval and signature on a written form.
Social Media and Email: Peak Clarity does maintain a Facebook account. We DO NOT use this to stay in contact with clients. Know that posting to our Facebook page may compromise your privacy. We do not solicit reviews or testimonials. Email is inherently not secure. We do respond to email but don’t guarantee the confidentiality of email communications.
Important Office Policies and Recommendations: Please review and indicate your understanding of each:
YES answers in this following section may require MEDICAL CLEARANCE.
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Beginning January 1, 2020, Colorado state law protects you* from “surprise billing,” also known as “balance billing.” These protections apply when:
- You receive covered emergency services, other than ambulance services, from an out-of-network provider in Colorado, and/or- You unintentionally receive covered services from an out-of-network provider at an in-network facility in Colorado
What is surprise/balance billing, and when does it happen?If you are seen by a health care provider or use services in a facility or agency that is not in your health insurance plan’s provider network, sometimes referred to as “out-of-network,” you may receive a bill for additional costs associated with that care. Out-of-network health care providers often bill you for the difference between what your insurer decides is the eligible charge and what the out-of-network provider bills as the total charge. This is called “surprise” or “balance” billing.
When you CANNOT be balance-billed:Emergency ServicesIf you are receiving emergency services, the most you can be billed for is your plan’s in-network cost-sharing amounts, which are copayments, deductibles, and/or coinsurance. You cannot be balance-billed for any other amount. This includes both the emergency facility where you receive emergency services and any providers that see you for emergency care.
Nonemergency Services at an In-Network or Out-of-Network Health Care ProviderThe health care provider must tell you if you are at an out-of-network location or at an in-network location that is using out-of-network providers. They must also tell you what types of services that you will be using may be provided by any out-of-network provider.
You have the right to request that in-network providers perform all covered medical services. However, you may have to receive medical services from an out-of-network provider if an in-network provider is not available. In this case, the most you can be billed for covered services is your in-network cost-sharing amount, which are copayments, deductibles, and/or coinsurance. These providers cannot balance bill you for additional costs.
Additional Protections- Your insurer will pay out-of-network providers and facilities directly. - Your insurer must count any amount you pay for emergency services or certain out-of-network services (described above) toward your in-network deductible and out-of-pocket limit.- Your provider, facility, hospital, or agency must refund any amount you overpay within sixty days of being notified.- No one, including a provider, hospital, or insurer can ask you to limit or give up these rights.
If you receive services from an out-of-network provider or facility or agency OTHER situation, you may still be balance billed, or you may be responsible for the entire bill. If you intentionally receive nonemergency services from an out-of-network provider or facility, you may also be balance billed.
- If you want to file a complaint against your health care provider, you can submit an online complaint by visiting this website: https://www.colorado.gov/pacific/dora/DPO_File_Complaint.
- If you think you have received a bill for amounts other than your copayments, deductible, and/or coinsurance, please contact the billing department, or the Colorado Division of Insurance at 303-894-7490 or 1-800-930-3745.
*This law does NOT apply to ALL Colorado health plans. It only applies if you have a “CO-DOI” on your health insurance ID card.- Please contact your health insurance plan at the number on your health insurance ID card or the Colorado Division of Insurance with questions.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
You have the right to:
You have some choices in the way that we use and share information as we:
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
Ask us to correct your medical record
Request confidential communications
Ask us to limit what we use or share
Get a list of those with whom we’ve shared information
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
File a complaint if you feel your rights are violated
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
In the case of fundraising:
We typically use or share your health information in the following ways.
Treat you
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
Do research
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
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