Neuroserenity

Informed Consent Form

Informed Consent & Agreement for Therapeutic Services

Introduction

This document is intended to provide important information to you regarding your therapeutic service at NEUROSERITY. Please read the entire document carefully and be sure to ask your Provider any questions that you may have regarding its contents before signing it. You may have questions about your Provider, your Provider’s qualifications, therapeutic service, or anything not addressed here. It is your right to have a complete explanation for any questions you may have, now or in the future. Please feel free to ask questions or share any concerns that may arise. Although your Provider knows this may be uncomfortable at times, your openness and honesty will allow your Provider to better serve you.

Information about Your Provider.

Whenever you wish, your Provider will discuss his/her professional background with you and provide you with information regarding his/her experience, education, special interests, and professional orientation. Please feel free to ask questions at any time about the above, and anything else related to your therapeutic service, or other concerns.

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Fees

The initial diagnostic evaluation is billed at $250. Following the initial diagnostic evaluation, the hourly rate for services is $180/60-minute session. Fees for  sessions lasting for more than 60 minutes will be assessed on a pro rata basis in 5-minute increments.

NEUROSERITY reserves the right to adjust these fees at any time. You will be notified of any fee adjustment in advance. It is required that fees be paid at the time that services are rendered. Only under extraordinary circumstances will NEUROSERITY approve an agreement that specifies an alternative payment procedure.

Providers at NEUROSERITY bill for their professional time for any services requiring longer than five minutes. This includes travel time for appointments outside of the office, phone calls with you or a third party, time spent preparing letters and documents, etc.

Delinquent Accounts.

You understand that you are responsible for all charges incurred and that services must be paid in full at the time of each visit, unless other arrangements have been made in advance. You understand that NEUROSERITY may elect to end your therapeutic service if timely payment is not made. You understand and agree that all unpaid bills are your responsibility and that should your bill become 90 days delinquent, your account will be turned over for collection. If this occurs, you understand and agree that you will be responsible for any additional costs of collection, including but not limited to interest, attorney’s fees, court costs, etc. If for some reason you find that you are unable to continue paying for your , please inform your Provider, who will help you to consider any other options that may be available to you at that time.

Insurance

At NEUROSERITY, we are in-network with many major insurance providers and will handle the claims process directly on your behalf. Our administrative team verifies benefits, obtains necessary authorizations, and submits bills to your insurer to simplify your experience.

Please Note: You are responsible for any copays, coinsurance, or unmet deductible amounts at the time of service. Coverage is determined by your insurer and typically requires a qualifying, diagnosable mental health condition. Any related diagnosis will become part of your permanent medical record. While we manage billing, we encourage you to understand your plan’s specific benefits, limits, and any out-of-network implications. Please discuss any coverage concerns directly with your Provider.

Appointment Scheduling

Appointment Scheduling and Cancellation Policies Sessions are typically scheduled to occur one time per week, but your Provider may suggest a different amount of sessions depending on the nature and severity of your concerns. Your consistent attendance greatly contributes to a successful outcome. Scheduled appointment times are reserved especially for you. If an appointment is missed, or canceled with less than 24- hours’ notice, you will be charged the full fee for that missed session. This fee will not be reimbursable by your insurance company.

Collaboration with Other Professionals.

In order to provide quality services, your Provider may need to collaborate with other professionals, such as your physician, psychiatrist, past therapists, and/or other mental health professionals. You will be asked to complete a release of information authorizing these exchanges. Your Provider will also ask you to inform your primary care physician that you are entering therapeutic service at NEUROSERITY; you have the right to decline, but your Provider will document that the request was made.

Risks and Benefits of Therapeutic service.

You should discuss with your Provider any concerns you have regarding your progress. Due to the varying nature and severity of problems and the individuality of each Client, your Provider will be unable to predict the length of your therapeutic service or to guarantee a specific outcome or result.

Professional Consultation
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Professional consultation is an important component of an effective therapeutic practice. As such, your Provider regularly participates in clinical, ethical, and legal consultation with appropriate professionals.

Provider-Client Privilege.

The information disclosed by you, as well as any records created, is subject to the Provider-Client privilege. The Provider-Client privilege results from the special relationship between Provider and Client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-Client privilege. Typically, the Client is the holder of the Provider-Client privilege. If your Provider receives a subpoena for records, deposition testimony, or testimony in a court of law, he or she will assert the Provider- Client privilege on your behalf until instructed, in writing, to do otherwise by you or your representative. You should be aware that you might be waiving the Provider-Client privilege regarding your entire therapeutic service if you make your mental or emotional state an issue in a legal proceeding. You should address any concerns you might have regarding the Provider-Client privilege with your attorney.

Records and Record Keeping.

Your Provider may take notes during sessions, and will also produce other notes and records regarding your therapeutic service. These notes constitute clinical and business records, which by law your Provider is required to maintain. Such records are the sole property of the Provider. Should you request a copy of your Provider’s records, such a request must be made in writing. Your Provider reserves the right to provide you with a therapeutic service summary in lieu of actual records. Your Provider also reserves the right to refuse to produce a copy of the record under certain circumstances, but may, as requested, provide a copy of the record to another treating health care provider. Records are maintained for seven years following termination of service. After seven years, your records will be destroyed in a manner that preserves your confidentiality.

Confidentiality

The information disclosed by you is generally confidential and will not be released to any third party without written authorization from you, except where required or permitted by law. Exceptions to confidentiality include, but are not limited to, situations where you pose a threat of serious harm to yourself or someone else; cases involving suspected child, elder or dependent adult abuse; cases in which your Provider is court-ordered to testify or produce records; or as outlined in the “Notice of Privacy Practices.”

Therapist Availability/Emergencies.

Please note that your Provider will often not be readily available via telephone. You may leave a message for your Provider at any time on the NEUROSERITY confidential voicemail at (619) 365-5687. If you wish for your Provider to return your call, please be sure to leave your name and phone number(s), along with a brief message concerning the nature of your call. Non- urgent phone calls are generally returned within 48 hours during normal workdays (Monday through Friday). If you have a situation that requires more urgent attention, please discuss appropriate contact options with your Provider. 

Please do not use e-mail for urgent situations. NEUROSERITY does not provide 24- hour emergency care. Therefore, we expect that in crises and life-threatening emergency situations you will call 911 or go to the nearest hospital emergency department for assistance. You may also call the 24-hour hotline, (800) SUICIDE [(800) 784-2433], if you have a life-threatening emergency. If an urgent situation does arise, it is expected that you will leave a message for your Provider describing the nature of your status. If your Provider is out of the office for an extended period of time, you will be given the name and telephone number of the covering Provider.

E-mail and Phone Communication.

Some Clients prefer to communicate about appointment times or other administrative issues via e-mail. You understand that confidentiality of e-mail communications with your Provider cannot be guaranteed. E-mails go through several intermediate stations before reaching their destination. Someone at any point along the line could potentially access electronic communications and even store the messages contained within. E-mails may remain stored in various places of a computer system and could surface at a later time. Computers, particularly those on DSL lines, are vulnerable to electronic eavesdropping. In addition, once the e-mail is received by you, someone may be able to access your e-mail account and read it. This may include your employer if you use a work-related e-mail address. For these reasons, sending any clinical or other sensitive information via e-mail is strongly discouraged. Please use the telephone for anything urgent or time-sensitive, as your Provider cannot guarantee that any particular e- mail will be read and responded to within any particular period of time.

Client Litigation.

Your Provider will not voluntarily participate in any litigation or custody dispute in which you and another individual, or entity, are parties. NEUROSERITY has a policy of not communicating with Clients’ attorneys and will generally not write or sign letters, reports, declarations, or affidavits to be used in any Client’s legal matter. Your Provider will generally not provide records or testimony unless compelled to do so. Should your Provider be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving you, the customary hourly rate (see “Fees” above) applies to any time spent for preparation, travel, or other time in which your Provider has made him/herself available for such an appearance.

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