Neurobehavioral Health Associates (NHA) is an
independent, limited liability private practice providing a range of
mental health and neuropsychological services. NHA has no affiliation
with any of the other professionals in the same office building. The
following information concerns the nature of the services you will be
receiving, and your rights and responsibilities in this process. Please
read this statement carefully and make sure you understand it and agree
to its terms before signing.
In working with patients I may draw upon a variety
of techniques to address the diverse problems which bring people into
therapy. Much of my work has a cognitive and behavioral base and is
geared toward helping people understand their interactions with the
world and to change patterns of behavior that are unhealthy or
unproductive. Attempts are also made to help the person gain insight
into her/himself and achieve relief from any conflict which causes
distress and unhappiness. Therapeutic sessions usually occur on a weekly
basis and length of sessions are typically fifty minutes. It is your
responsibility to participate actively in the nature and direction of
your therapy; I encourage you to ask questions and express your opinions
and reactions openly. I will do everything in my power to get you the
help you need. You have the right at any time to request a change of
therapy, to be referred to another therapist, or to stop treatment.
Basic fees are established and agreed upon during
the first meeting. Evaluations are billed as a separate fee from
therapy. It is the patientís responsibility to provide our office with
current accurate insurance information. The insurance co-pay is due at
the time of service, or payment in full for services unless other
arrangements have been made. Cancellations must be made at least 48
hours before the appointment, or a missed appointment fee will be
charged. Any unpaid balance remaining after insurance payment is the
patientís responsibility, and if necessary unpaid accounts will be
referred to a collection agency. For a list of current fees,
We are required by applicable federal and state
law to maintain the privacy of your health information. The identity of
patients and information that is discussed in therapy sessions will be
held confidential with the following exceptions:
1) I have written permission from the
patient to share this information.
2) If I become aware that the patient is
physically or sexually abusing a child or I have reason to
suspect a child is at risk for abuse it is a mandatory
requirement that authorities be notified.
3) If a patient is unable to care for
her/himself, threatens dangerous actions or bodily harm to
her/himself or to other persons, it is my responsibility to warn
the family of the individual, the threatened person or his or
her family and/or appropriate authorities.
4) If I am served with a Court order that
requires me to release my records.
5) In the event of nonpayment for
services, necessary information may be provided to a collection
6) If payment is to be made by a third
party, such as an insurance or health care company, that company
may require information about the nature of the problem and the
treatment process in order to approve payment.
7) I may provide you with appointment
reminders (such as voicemail messages, postcards, or letters).
8) I may disclose limited health
information to a family member, friend, or other person to the
extent necessary to help with your healthcare.
We keep a record of the health care services we
provide you for at least seven years. You may ask to see and copy that
record. You may also ask us to correct that record. We will not disclose
your record to others unless you direct us to do so, or unless there is
a legal requirement that compels us to do so. In compliance with ethical
standards of the American Psychological Association, test protocols and
raw test data will be released ONLY to another doctoral level
Psychologist or Neuropsychologist trained in their administration and
interpretation. Except in the case of some administrative or forensic
evaluations, as noted in the "Evaluation Process" section above, a
patient has the right to know the results of his/her psychological
evaluation. A review of records is designed to clarify any
misinterpretations, answer any questions, and hopefully, ease any
discomfort you might have about your record.
If you have reason to believe that I have acted in
an unprofessional or unethical manner you are encouraged to bring this
to my attention. I am aware that people who undergo psychotherapy or
psychological evaluations are often under stress. Please be assured that
complaints to me about my behavior will not prejudice your case. If you
feel I have not responded adequately to your complaints you may lodge a
complaint with the Department of Health Examining Board of Psychology,
1300 SE Quince Street, P.O. Box 47868, Olympia, WA 98504-7868, or with
the American Psychological Association Ethics Committee, 1200 17th St.
NW, Washington, D.C. 20036.