PSYCHOTHERAPY, BIOFEEDBACK & NEUROFEEDBACK
The purpose of this document is to ensure that each of our clients has had the opportunity to read more about manner in which services are provided by the staff of Focus Centers of Asheville.
Although there can be no guarantee of success in the provision of our services, you are entitled to prompt and skillful attention to your needs by a competently trained health provider or learning specialist. If we are unable to help you with the problem you are experiencing, we will endeavor to refer you to someone else who can.
There are both federal laws and state regulations governing the protection of confidential health service records. For your benefit, we distribute in our office a separate document entitled, “Notice Regarding Our Patient Confidentiality Practices.” If you have not seen that document, please feel free to ask your therapist for one.
Other than the specific exceptions described below, you have the right to confidentiality in all of your contacts with our center. Your provider will not tell anyone else what you have disclosed and will not let anyone know that you are in treatment or testing without your prior written permission. You may direct us to share information with whomever you choose, and you can change your mind and revoke that permission at any time.
The following are legal exceptions to your right to confidentiality. These exceptions would require your provider to disclose information to others about you or your treatment, training or testing.
1. If your provider has good reason to believe that you intend to harm another person, s/he must attempt to inform that person and warn them of your intentions. S/he must also contact the Police and ask them to protect your intended victim.
2. If we have good reason to believe that you are abusing or neglecting a child or a vulnerable adult, or if you give information about someone else who is doing this, we
must inform Child Protective Services within 48 hours and Adult Protective Services immediately.
3. If we believe that you are in imminent danger of harming yourself and we cannot reach an agreement that will assure your safety, we are legally bound to break confidentiality and call the police.
4. If you are using an insurance company to provide reimbursement for services, they are entitled to know your diagnosis, your treatment or testing dates and your treatment plan.
5. If a court order is issued that legally compels us to disclose information, we will provide the required information.
6. If a parent or legal guardian insists upon a copy of the clinical record of their child, that information will be provided.
The rates for a Certified Biofeedback Provider are $65-75 for each 30-45 minute session. The fees for psychotherapy or counseling services provided by a Licensed Professional Counselor are charged at the rate of $110 for an hour. The fees for psychotherapy with a Licensed Doctoral Degree professional are $130 an hour and $75 a session for 30 minutes of biofeedback. Biofeedback fees with a licensed clinician can vary depending on the length of time scheduled for your appointment. Testing fees vary according to the test selected and the amount of time required to administer, score and report on test results. Payment for all services is due at the time that services are rendered. Most major credit cards are accepted.
Health insurance may be used to pay for some of our services with some providers. If you would like to utilize health insurance for full or partial payment of services, we will endeavor to call your insurance company to ask them the extent of your coverage and then report to you what we learn. You may be required to pay for sessions until your deductible is met. If you have a co-pay, it will be due at the conclusion of each session. It is your responsibility to inform us if your insurance requires prior authorizations before you can begin treatment. We will bill your insurance company directly following your sessions and wait for their payment. You are responsible for any unpaid balance after insurance has paid their portion.
If you would like to finance all or part of your fees for services, we also can refer you to financing companies that typically finance health expenses.
Appointments can be scheduled individually by each therapist or by calling the office and asking for the Office Manager. The length of your appointment is individually planned according to your training or treatment plan. Once an appointment is made, we require 24 hours notice for a cancellation in order to avoid a charge for late fee cancellation.
Methods of Communication
In addition to the central office phone number (828-281-2299), each member of our staff maintains an individual phone line extension with voice mail. These lines can be used to leave messages as well as to seek guidance in an emergency. If you are unable to contact your therapist in an emergency, call 911 or seek transportation to your nearest hospital emergency room.
If you elect to communicate with staff by email at some point in our work together, please be aware that email exchanges are not completely confidential and cannot be guaranteed protection by Focus Centers. For that reason we prefer to communicate confidential information by fax or encrypted communication.
Your signature below serves as your confirmation that you have had an opportunity to read and understand the above consent.
Print Name __________________________
Patient or Legal Guardian Signature _____________________________
417 Biltmore Ave, Suite 5-D Asheville, NC 28801 (828) 281-2299