Consent to Treatment
Neurofeedback / Psychotherapy
In case you want to read this before your intake...
I hereby authorize Rhonda Mateer Ross to provide neurofeedback and psychotherapy. I understand that the sessions are confidential and only information can be exchanged through my (or legal guardian's) consent unless it seems that I am at risk to myself or to others. I understand that neurofeedback training is used for a variety of conditions, which appear to be associated with irregular brain activity, including but not limited to ADHD, concussions, balance, psychosis, depression, bipolar, learning disabilities, anxiety, sleep, stroke, and seizure disorders. Training is recommended on the basis of empirical observation of improvement in clients with similar conditions. I understand that my insurance will be billed for the psychotherapy portion of my session but not the neurofeedback portion. I understand that EEG biofeedback (neurofeedback) requires placement of surface electrodes on my scalp (or my child’s) for the purpose of recording my EEG and the use of this signal to provide video displays and audio signals. The sensors do not “do anything” to my brain but are used to “read” the brain. The computer display provides the feedback needed for helping my (my child’s) brain learn to work more effectively. I understand that some individuals have reported that training may affect my body's response to medications for my condition and for unrelated conditions. I understand that I should not stop or alter any of my medications without consulting my physician /psychiatrist/specialist.
Specifically, I understand that should I be diabetic, it is important to monitor the effects of neurofeedback since my insulin requirements may change. I should continue ongoing therapies until otherwise advised by my physician. Should new symptoms develop, it is my responsibility to inform my health care providers including my neurofeedback practitioner. I understand that it is the client's (or legal guardian’s) own responsibility to monitor the subjective effects of training. Neurofeedback is based on the input of my, or my child’s report from day to day sessions as well as from the initial evaluation, and depends on the full participation of the client, i.e. his/her feedback about the effects of the training. The research literature indicates that there are some individuals who are apparently unaffected by training. Accordingly, the client is encouraged to evaluate progress after about ten sessions to determine if further training is indicated. Other referrals may be initiated. Discussion is invited at this point or any time during the training. Daily journaling of symptoms and experiences is encouraged.
No representation is made that any individual client will improve from training. There is some indication that some client's improvement may fall off after the cessation of training. These individuals would benefit from periodic follow-up or booster sessions. The training is non-invasive and appears to be a harmless procedure as far as is known at present. No injuries are known or reported in the literature. I am aware that general, non-identifying information may be shared with Master BCIA Mentor Dr. Mike Griffin of Emporia, Virginia who may have treatment ideas based on information provided to him. Also, I am aware that that non-identifying information may be exchanged with the business accountant for taxes and billing purposes. A neurofeedback technician may assist in the sessions and this individual is bound by the same confidentiality and code of ethics that apply to the neurofeedback clinician. My insurance will also be given the minimal required information needed for billing purposes. By signing this form, I indicate my understanding of the principles set forth here and waive any claim of damages due to the training including worsening of my condition for which the training was undertaken, claimed side effects of the failure to improve with training. I agree to submit any dispute with Rhonda Mateer Ross to binding arbitration under the rules of the American Arbitration Association.