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 patient’s 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 patient’s responsibility, and if necessary unpaid accounts will be referred to a collection agency.
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 agent.
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.