Name of patient:____________________
Edward Jacobs, Ph.D. & Associates
Londonderry, NH 03053
OFFICE POLICIES AND CONSENT TO TREATMENT AGREEMENT
These policies have been
established to make psychological services as effective as possible, to minimize the possibility of any misunderstanding,
and to comply with certain legal requirements. Please read this thoroughly, and discuss any questions with me.
License and Code of Ethics
I am a New Hampshire Licensed Psychologist
(Edward Jacobs, Ph.D.) ◊ Independent Clinical Social Worker (Vicki Jacobs, MSW), governed by the Code of Ethics of the
American Psychological Association (Edward Jacobs, Ph.D.) ◊ National Association of Social Workers (Vicki Jacobs, MSW).
My license, or a current copy of it, is displayed in these offices. A copy of my professional Code of Ethics is available
in these offices for you to review at your request.
Qualifications and Scope of Practice
I received my graduate degree in the year 1981 (E. Jacobs), 1981 (V. Jacobs). My practice is a general
mental health practice that includes counseling, psychotherapy, and assessments with children, adolescents, adults, families
and groups, as well as consultation with agencies, organizations, and other professionals on mental health matters. There
might also be times when I testify in court as an expert witness. Psychologists also have training and experience in psychological
testing. Neurofeedback training and quantitative EEG are part of the practice of Edward Jacobs, Ph.D.
A copy of the Mental Health Bill of Rights is posted
in the waiting area or, if you are seen outside of the main office, will be provided to you.
Communication between you and me, as your psychotherapist, is confidential, and
will not be revealed to any other person or agency without your permission, unless under certain special circumstances. In
order to obtain your permission to release confidential information, I will ask for your permission in writing to release
information to a specified person or agency. That permission will have a time limit to it, and may be revoked at any time
Recognizing the benefit of second opinions, I may occasionally consult with a colleague about my work,
always protecting the identities of my clients.
There are also certain situations in which I would be legally or
ethically required to reveal information obtained during therapy to other persons and/or agencies without your permission.
These situations are as follows: 1) If you communicate "a serious threat of physical violence against a clearly identified
or reasonably identifiable victim or victims" or property, I am required by law to warn the intended victim(s) or the
police, or to obtain civil commitment of you to the state mental health system; 2) If you indicate a danger of hurting yourself
and refuse to accept further appropriate treatment, I may call your family, agencies, or other individuals who, in my opinion,
would assist in protecting your safety; 3) If I have any reason to suspect that a child or incapacitated adult has been abused
or neglected, I am required to report this to the appropriate state authority; 4) If I am aware of the existence of certain
occupationally related illnesses, communicable diseases, or critical health problems, I must report this to the appropriate
state agency. The law prohibits me , except under very limited circumstances, to disclose the identity of a person tested
for the HIV virus; 5) If you are involved in a civil commitment proceeding, in pursuing a personal injury action, or in filing
a workers' compensation claim, or if my conduct is being reviewed by licensing authorities, your privileged communication
may be waived; 6) If I am issued a court order to provide information, I will be required to comply with that order; 7) If
you have a serious or chronic mental illness, a person living with or providing care to you may be provided information concerning
diagnosis, admission to or discharge from a treatment facility, functional assessment, prescribed medications and side effects,
manifestations of the failure to take medications, treatment plans and goals, and behavior management strategies; 8) If you
are subject to an involuntary emergency psychiatric admission, I might be required to provide information essential to your
care; 9) If your treatment is related to an injury from a gunshot wound or other serious injury suspected to be caused by
a criminal act, I might be required to inform a law enforcement official.
If you give me permission to bill a third party for my services, I will release
information to that party necessary for the processing of that claim. If you choose to use your insurance coverage for my
services, most insurance agreements require you to authorize me to provide a clinical diagnosis, and sometimes additional
clinical information such as a treatment plan or goals, or a summary, or copies of reports, or in some cases, a copy of the
entire record. This information will become part of the insurance company files and some of it will probably be computerized.
You have the right to restrict disclosure of encounter information to your insurer if services are paid for out of pocket.
Sometimes information might be exchanged
between myself, my clients, or other entities that is transmitted electronically, such as in the form of faxes, emails or
electronic billing information. I will make every effort to safeguard the confidentiality of this information. Information
that is sent by me will only contain the minimal necessary information to accomplish its purpose. Information that is received
by me will be placed in your chart. Since computers can maintain information on their hard drives even when files have been
deleted, and since I have no control over the way in which other persons or organizations use or store the information that
they send to or receive from me, and since not all email and fax transmissions are encrypted, I cannot guarantee the confidentiality
of this information. If you do not consent to electronic communications, please inform me immediately, before beginning treatment,
so I can determine how to proceed. If you email or fax information to me, or if you request information from me that is emailed
or faxed, it is with the understanding that this information may not be encrypted and may be stored by other parties.
Individuals also have the right to request electronic copies of information that is held electronically.
You have the right to be notified in the event of a breach of the privacy
or security of your Protected Health Information.
Length of Appointments:
I will normally make 45 minutes available for your appointment from the scheduled start of your appointment time.
At times I may elect to extend the length of the appointment. I may also, by mutual consent, agree to meet for briefer periods
of time. I am normally available to you during our scheduled appointment times.
In an emergency, call 911 or go to your nearest emergency room, and then try
to contact me. I will attempt to return your call as soon as possible. PLEASE NOTE: If you choose to set up your telephone
line so it will not accept blocked calls, I might not be able to reach you in an emergency if I am out of the office, since
the telephones that I use outside the office might have blocked numbers.
I go about my normal routine during evenings
and weekends, and I am out of the office at various times during the week. Since I do not carry a beeper, and may be unreachable
immediately at times, there may be times when it will take me several hours or longer to return your call.
After evaluating your situation, I will discuss with
you my clinical impressions, and my recommendations for treatment, and decide with you which services are appropriate.
Length of Treatment:
The length of treatment varies according to
the needs of each individual client. In many instances, a client's goals can be accomplished with short-term treatment. In
other situations, it may be desired by the client or recommended by me, that treatment proceed over a longer period of time.
It is important to understand the limits of your insurance coverage and your own financial resources so you can make an informed
decision about the affordability of treatment. Many reimbursement plans are oriented towards a short-term treatment approach,
which is often appropriate. However, if a length of treatment is desired by you that is longer than your insurance company
approves, it is important to understand what your financial obligations will be.
Benefits and Risks:
Obtaining psychological services, such as counseling or psychotherapy, can have benefits and risks. Since participation
in these services often involve discussing unpleasant aspects of your life, you might experience uncomfortable feelings like
sadness, anger, guilt, anxiety, anger, frustration, loneliness and helplessness. On the other hand, obtaining psychological
services has also been shown to have benefits for people. It can lead to better understanding of oneself, better relationships,
solutions to specific problems, and significant reductions in feelings of distress.
Neurofeedback training also
can have benefits and risks. Since we are working with the ability of the nervous system to regulate attention and emotional
control, an individual might respond with feelings of anxiety, sadness, too much energy, too little energy, an excess of emotional
expression, a decrease in emotional expression, or changes in sleep. These effects tend to be temporary and, if they occur,
need to be communicated as soon as possible to your therapist so corrections in the training can be made. The benefits of
neurofeedback can include improved attention, improved processing of information, and improved emotional stability and control.
Psychological testing can be used to evaluate your intellectual, cognitive, emotional and personality functioning. The benefits
include obtaining information about yourself or your child about strengths and vulnerabilities, which can also help you plan
for personal, educational, vocational, psychological and parenting matters. Testing can also elicit feelings of sadness or
anxiety, from finding out about problems about which one was unaware, or confirming problems that one suspected were there.
In addition, psychological testing is often sought out or used for specific purposes, such as informing decisions regarding
child custody, educational planning, or eligibility for benefits. The results might not support the outcome that you wish,
and you might experience anger or disappointment.
It is important to understand that the tester must base his or
her conclusions on the information contained in the tests, the patient's history and demeanor, and the tester's clinical judgment,
rather than on a need to please the patient or obtain a certain outcome. It is our policy to change the content of our psychological
testing reports only under rare circumstances, such as to correct factual errors, further clarify clinical impressions, or
protect someone from serious harm.
Maintenance of Records:
I maintain a file for each client. The file includes information related to intake, diagnosis, treatment plan,
billing, consent to treatment, treatment notes, and any other written or electronic information I received from or about the
client. Treatment notes include the date of each session and might include information about facts or issues discussed, and
treatment recommendations. The client is entitled to a copy of the records for a fee which covers copying and administrative
costs. The client can also see a copy of the records. If you wish to review a copy of your record, I recommend that you review
it with me so we can discuss its contents.
Release of Records:
I am able to release your records, or any part of them, with your written permission, provided you pay for any
reasonable copying or administrative costs in advance. Furthermore as a condition of hiring our services, you agree that records
or reports will not be released to you or other parties if you have an outstanding balance in your account with the practice.
Caretaking of Records in the Case of Incapacity;
In the event of the incapacity
or death of a clinician in this practice, your records will be managed by either Edward Jacobs, Ph.D. or Vicki Jacobs, MSW.
The treatment of a minor must be authorized by a parent or guardian (with
limited exceptions). In the treatment of minors, parents (even non-custodial parents) have the right to access and authorize
release of information. In order for me to be effective in working with minors, however, the minors need to have some degree
of privacy in order to trust me and to talk about their most important concerns.
Therefore, if you are a parent
of a minor who is receiving services from me, you agree that the information that I reveal to you about the minor will be
limited to information necessary to preserve the safety of the minor and others, and information that, in my opinion, will
help you to be helpful to the minor in the context of your relationship with him or her. You agree that it will be at my discretion
to reveal specific content from my meetings with the minor.
records of couple's sessions contain sensitive information about each person. Therefore, in the case of couples treatment,
whether the members of the couple are married to each other, unmarried, separated or divorced, both members of the couple
agree that records will only be released by joint consent. In the event of a disagreement, the records will not be released
without a court order.
individual treatment, group therapy is not protected by law. Client concerns about confidentiality should be discussed prior
to beginning treatment.
Professional Boundaries and Sexual Misconduct:
psychotherapists are obligated to establish and maintain appropriate professional boundaries (relationships) with present
and past clients and their family members.
Sexual relations by a mental health professional with a client
or a former client (a person who was given psychotherapy within two years prior to sexual relations with the psychotherapist)
is considered sexual misconduct and is subject to disciplinary action.
Billing and Insurance
My billing rate is $250 for initial appointments, $250 per 45 minute
session, and $250 per 45 min for related work. Related work includes, but is not limited to, telephone consultations; my attendance
at meetings on your behalf, with your consent, including travel time; review of records or files; and the preparation and
writing of reports. Neurofeedback self-pay fee is $175 per half-hour training session. The fee for a quantitative EEG is $950.
Payment for services is due at the time of service or, in the case of related work, upon the receipt of a bill for my services.
At times, I require pre-payment for my services.
certain circumstances, I may agree to bill your insurance directly for my services, with the exception of related work and
missed appointments (see below), which are generally not covered by insurance benefits. If your insurance or other third party
is billed for my services, you are still ultimately responsible for payment of all fees, unless there are exceptions to this
provision in my contract with the insurance company or third party. As stated earlier, it is important to understand the limits
of your insurance coverage and your own financial resources so you can make an informed decision about the affordability of
As a client, you agree to an insurance waiver stipulating that any fees that are not paid by your insurance
company within 90 days of billing will be billed directly to you, and that you will be responsible for payment of the claim.
You are responsible for finding out exactly what services your insurance policy covers, including deductibles, copayments
and coverage limitations. Many insurance companies and managed care plans also require advance authorization before they will
provide reimbursement for services. You are responsible for finding out the services that have been authorized, the number
of sessions or hours, the time limitations, and the authorization number which is necessary for billing. It is your responsibility
to keep current with this information so you know when your authorized coverage will expire. If you do not find out or provide
the information which is required of you, you agree to be fully responsible for payment of my full fee for these services.
In addition to the "related work and missed appointments," that are stated above, there are other services that
I might provide that either might not covered by, for which I will not bill to your insurance company. These services include,
but are not limited to, neurofeedback training and some types of psychological testing. The lack of insurance reimbursement
available for these services will be discussed with you, when appropriate. In order to receive these services, you agree to
waive insurance billing and to pay for them directly.
Monthly Statements and Payment:
If you have a balance due, or if you request it, you will be provided with a monthly statement of your account.
All outstanding balances are due upon receipt of the statement, unless another arrangement has been agreed upon. You agree
to have unpaid balances billed to your credit card if other payment arrangements cannot be made.
For checks that
are returned to us for insufficient funds, you will be assessed a returned check fee of up to $25.
If you are having some difficulty making payment because of your financial situation,
it is important to let me know immediately so we can work out some plan or timetable for payment that will be manageable for
you. As long as you communicate with me about your situation, I am confident that we can work out a reasonable arrangement
If your account is more than sixty (60) days in arrears, and suitable arrangements for payment
have not been agreed to, I reserve the option of referring your account to a collection agency or an attorney to pursue collection
of the unpaid balance. If such action is necessary, the costs of bringing that action or securing that collection will be
billed to you, which will be an additional 35% of the balance.
If an outstanding balance remains in your account
after you have left therapy, I will make a reasonable effort to contact you, usually by mail, to arrange payment. If you are
unable to pay your balance in full at that time, I will be happy to work out a payment plan with you at your request. However,
if after reasonable efforts to collect from you have failed, I reserve the option of referring your account to a collection
agency or an attorney to pursue collection of the unpaid balance, and to bill you for the costs of bringing that action or
Payments can be made with Visa, MasterCard, American Express or Discover.
Appointment times are reserved for you to the exclusion of anyone
else. If you cancel or miss your appointment time, for any reason, you will be billed directly for my full fee, not the fee
that I might have contracted for with your insurance company, which only pertains to services which I provide that is covered
by the insurance company. This fee cannot be billed to your insurance or other third parties. Your signature indicates your
agreement with this policy.
Charging for missed appointments is not intended to be punitive. My income depends
on my being able to use my available time. I have promised that hour to you and, if it is not used by you, and I cannot make
use of it, I cannot make it up.
I try to be as flexible as possible with this policy and, therefore, there are
certain exceptions. You will not be charged for a missed appointment: 1) If you cancel your appointment ahead of time and
we can reschedule your appointment during the same calendar week; 2) If you cancel ahead of time and I can fill the time by
scheduling another client in that time. If you cancel and cannot reschedule, I will make every effort to fill the time with
another client; 3) If you are taking a vacation and inform me at least several weeks in advance; 4) If you or your child is
ill and this illness prevents your attendance at our session.
Complaints and Privacy Inquiries:
of professional misconduct should be directed to the New Hampshire Board of Psychology, 129 Pleasant Street, Concord, NH 03301,
Complaints regarding the privacy of confidential information, the policies and procedures of this
practice, or professional behavior within this practice, can be made by contacting, by telephone or in writing: Edward Jacobs,
Ph.D. at extension 10.
Edward Jacobs, Ph.D. & Associates
__________________________________________ (Name of Patient)
- I have received and read, and understand and agree to, the OFFICE
POLICIES AND CONSENT TO TREATMENT AGREEMENT of Edward Jacobs, Ph.D. & Associates, and agree to have Edward Jacobs, Ph.D.
& Associates and the clinicians associated with Edward Jacobs, Ph.D. & Associates provide professional services to
myself or dependent family member. I have had the opportunity to ask questions, and agree to receive services from the practice.
I consent to my protected health information being used by Edward Jacobs, Ph.D. & Associates to provide psychological
services, and to maintain health care operations. I understand that this complete document, including the signature page,
is available for my review online at www.jacobsassociates.org and at the office of Edward Jacobs, Ph.D. & Associates.
- I authorize and agree to pay for any and all services that I receive
that have not been authorized or not paid for or have been denied by my health insurance or that have been paid at a rate
reduced from the usual and customary fee by my health insurance carrier. These services might include, but are not limited
to, initial appointments ($250 per 45 min.), counseling and psychotherapy, consultations, report writing, document review
and preparation, telephone calls, travel time, missed appointments ($250 per 45 min.), neurofeedback ($175 per half hour),
quantitative electroencephalography ($950), psychological, neuropsychological and educational testing, tutoring, and court
time and testimony (fees determined on case by case basis). The fees for these services have been discussed with me. I AGREE
TO WAIVE THE RIGHT TO BILL MY INSURANCE FOR NEUROFEEDBACK OR QEEG SERVICES AND I AGREE TO PAY FOR THESE SERVICES DIRECTLY.
- I agree to indemnify and hold harmless Edward Jacobs, Ph.D. & Associates and any of
its employees or consultants for any use made of its evaluations, testimony, consultations, reports or records by any third
RELEASE OF INFORMATION
- I authorize the release of protected health information,
both verbal and written, from Edward Jacobs, Ph.D. & Associates, to my/my child's primary care physician,__________________________
of ___________________________________ related to my/my child's mental health and health concerns.
- I authorize the
release of any medical or other information necessary to process health insurance claims.
- I authorize payment of
medical benefits to Edward Jacobs, Ph.D. & Associates, 12 Parmenter Road, Londonderry, NH 03053, for services rendered.
I authorize the release of information to the Insurance Commissioners of the States of New Hampshire and Massachusetts related
to claims for services that are billed to my insurance that are not processed accurately.
- I authorize Edward Jacobs,
Ph.D. & Associates to bill any outstanding patient balance each month to the credit card indicated below.
authorize and agree to the above conditions: Signature and Date: _______________________
Visa/MasterCard/Discover #: Exp.:
Name on card: Security Code: