Fonda Hart, RN, LMFT

Licensed Marriage and Family Therapist

Forms

BrainPaint Intake Form

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Consent For Treatment Of A Minor

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Agreement For Service / Informed Consent

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Acknowledgement Of Receipt Of Notice Of Privacy Practices

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Consent for BrainPaint Neurofeedback

Introduction
This agreement is intended to provide you with important information regarding the policies of Fonda Hart, LMFT (herein “Therapist”) and to clarify the terms of the therapeutic relationship between the neurofeedback provider (herein “Provider”) and the client (herein “Client”). Any questions or concerns regarding this Agreement should be discussed with Fonda Hart prior to signing it.
About Neurofeedback
Brainpaint neurofeedback has been available to the public for about 20 years. Research has been done by several universities, including Harvard and UCLA; numerous studies have been published demonstrating its efficacy.

In order for neurofeedback to be effective, Best Practices requires a minimum of two sessions per week. Sessions less than twice weekly are not recommended. If you are unable to commit to, and participate in at least two sessions per week, it is best to wait until you are able to commit and follow through. Individual outcomes cannot be guaranteed. 95% of people experience short-term improvement, 5% of people find no benefit. A few clients may experience short-term side effects, which are reversible within a few days or with a subsequent session. No long-term or permanent side effects have been reported. The gains made during the neurofeedback process are generally permanent.
Session Payment and Insurance
Payment for sessions are due in full at the time of Client’s session. Payments can be made by cash, check, Venmo or card payments.

Neurofeedback may or may not be a covered benefit with your insurance policy. Fonda Hart is not a contracted provider with any insurance company. Therapist’s office can verify benefits upon request. If neurofeedback is a covered benefit with your insurance, a superbill or visit statement will be provided for Client to submit. Alternatively, Therapist is generally willing to courtesy bill, upon request. Regardless of insurance coverage, Client is responsible for full payment of all session fees. Reimbursement will be between Client and Insurance company.

If Client does not pay the balance in full, and Therapist has attempted unsuccessfully for 3 months to collect the balance owed, Client will be referred to a collections agency to recover the unpaid balance. When referral to Collections is made, adjustment or fee reductions will be reversed, and all sessions will be invoiced at full fee.
Session Payment and Insurance Consent*
I understand that I am fully responsible to Therapist for all charges, including unpaid charges by insurance or any other third-party payor.
24 Hour Cancellation Policy Consent
In the event that Client needs to cancel a session, Provider is to be notified at least 24 hours in advance. Client is responsible for payment of session fee for any missed sessions if 24-hour notice was not given. Insurance does not reimburse for missed or late-cancelled sessions.
24 Hour Cancellation Policy Consent*
I understand that I am responsible to pay for missed sessions and late-cancelled sessions.
Confidentiality
Services provided, and any information disclosed by Client, are generally confidential and will not be released or disclosed to any third party without written authorization from Client, except where required or permitted by law. Exceptions to confidentiality include, but are not limited to, reporting child, elder, and dependent adult abuse; reporting a serious threat of violence toward a reasonably identifiable victim, or reporting risk of self-harm for intervention.

Although Therapist has an encrypted E-mail system, Client should be aware that E-mail is not as secure a telephone. Client assumes the risk for any violation of confidentiality that occurs in the course of E-mail or text communication. E-mail or text communication can be used for scheduling and other logistical needs but not for actual treatment.
Confidentiality Policy*
I have read and understand the confidentiality policy
Privacy Practices
Terms of Service*
Notice of Privacy Practices 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. I. I HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH lNFORMATION (PHI) As your healthcare provider, I am legally required to protect the privacy of your PHI. This includes information that can be used to identify you that I've created or received about your past, present, or future health or condition, the provision of health care to you, or the payment of this health care. I must provide you with this Notice about my privacy practices, and such Notice must explain how, when, and why I will “use” and “disclose” your PHI. A “use” of PHI occurs when I share, examine, utilize, apply, or analyze such information within my practice; PHI is “disclosed” when it is released, transferred, has been given to, or is otherwise divulged to a third party outside of my practice. With some exceptions, I may not use or disclose any more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made. And, I am legally required to follow the privacy practices described in this Notice. However, I reserve the right to change the terms of this Notice and my privacy policies at any time. Any changes will apply to PHI on file with me already. Before I make any important changes to my policies, I will promptly change this written Notice and post a new copy of it in my office and on my website (if applicable). You can also request a copy of this Notice from me, or you can view a copy of it in my office or at my website, which is located at www.fresnocounseling.com. II. HOW I MAY USE AND DISCLOSE YOUR PHI. I will use and disclose your PHI for various reasons. For some of these uses or disclosures, I will need your prior written authorization; for others, however, I do not. Listed below are the different categories of my uses and disclosures along with some examples of each category. A. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. I can use and disclose your PHI without your consent for the following reasons: 1. For Treatment. I can use your PHI within my practice to provide you with mental health treatment, including discussing or sharing your PHI with my trainees and interns. I can disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are involved in your care. For example, if a psychiatrist is treating you, I can disclose your PHI to your psychiatrist to coordinate your care. 2. To Obtain Payment for Treatment. I can use and disclose your PHI to bill and collect payment for the treatment and services provided by me to you. For example, I might send your PHI to your insurance company or health plan to get paid for the health care services that I have provided to you. I may also provide your PHI to my business associates, such as billing companies, claims processing companies, and others that process my health care claims. 3. For Health Care Operations. I can use and disclose your PHI to operate my practice. For example, I might use your PHI to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided such services to you. I may also provide your PHI to my accountant, attorney, consultants, or others to further my health care operations. 4. Patient Incapacitation or Emergency. I may also disclose your PHI to others without your consent if you are incapacitated or if an emergency exists. For example, your consent isn't required if you need emergency treatment, as long as I try to get your consent after treatment is rendered, or if I try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) and I think that you would consent to such treatment if you were able to do so. B. Certain Other Uses and Disclosures Also Do Not Require Your Consent or Authorization. I can use and disclose your PHI without your consent or authorization for the following reasons: 1. When federal, state, or local laws require disclosure. For example, I may have to make a disclosure to applicable governmental officials when a law requires me to report information to government agencies and law enforcement personnel about victims of abuse or neglect. 2. When judicial or administrative proceedings require disclosure. For example, if you are involved in a lawsuit or a claim for workers’ compensation benefits, I may have to use or disclose your PHI in response to a court or administrative order. I may also have to use or disclose your PHI in response to a subpoena. 3. When law enforcement requires disclosure. For example, I may have to use or disclose your PHI in response to a search warrant. 4. When public health activities require disclosure. For example, I may have to use or disclose your PHI to report to a government official an adverse reaction that you have to a medication. 5. When health oversight activities require disclosure. For example, I may have to provide information to assist the government in conducting an investigation or inspection of a health care provider or organization. 6. To avert a serious threat to health or safety. For example, I may have to use or disclose your PHI to avert a serious threat to the health or safety of others. However, any such disclosures will only be made to someone able to prevent the threatened harm from occurring. 7. For specialized government functions. If you are in the military, I may have to use or disclose your PHI for national security purposes, including protecting the President of the United States or conducting intelligence operations. 8. To remind you about appointments and to inform you of health-related benefits or services. For example, I may have to use or disclose your PHI to remind you of your appointments, or to give you information about treatment alternatives, other health care services, or other health care benefits I offer that may be of interest to you. C. Certain Uses and Disclosures Require You to Have the Opportunity to Object. 1. Disclosures to Family, Friends, or Others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
- I agree to the Terms of Service
Click Here to Download a Copy of our Privacy Practices
Acknowledgement
By signing below, Client acknowledges that he/she has reviewed and fully understands the terms and conditions of this Agreement. Client has discussed any questions with Therapist and has had his/her concerns addressed to Client’s satisfaction. Client agrees to abide by the terms and conditions of this Agreement and consents to participate in Brainpaint neurofeedback. Client has a right to discontinue neurofeedback sessions at any point. Therapist maintains the right to terminate the treatment process if warranted.
Client Name*
Date*
Month
Day
Year
Signature of Client (or Authorized Representative)*
Parent or Guardian Name (For Minor)
Signature of Parent or Guardian (For Minor)

Fonda Hart, RN, LMFT

Licensed Marriage and Family Therapist

Forms

BrainPaint Intake Form

Consent For Treatment Of A Minor

Agreement For Service / Informed Consent

Acknowledgement Of Receipt Of Notice Of Privacy Practices

Consent for BrainPaint Neurofeedback

Introduction

About Neurofeedback

Session Payment and Insurance

24 Hour Cancellation Policy Consent

Confidentiality

Privacy Practices

Acknowledgement