Your decision to seek mental health services was undoubtedly a serious one arrived at after considerable thought. Whether you were referred to us by your medical provider, urged to seek counseling by family or friends, or came because of problems and feelings only you know about, the decision to come here was yours. We congratulate you on taking this important step forward on your path to mental health recovery and are honored that you are considering our clinic as your service provider. The information below details the procedures and policy guidelines in place at True Balance Ltd. Clients requesting services are asked to read this information and to provide a signature that attests to your understanding and agreement with these policies and procedures.
What are Psychological Services/Therapy/Counseling?
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and client, and the particular problems you bring forward. There are many different methods your therapist may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things you talk about both during sessions and at home.
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. There are no guarantees of what you will experience.
Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, your therapist will be able to offer you some first impressions of what the work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with your therapist.
Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about any procedures, you should discuss them whenever they arise. If your doubts persist, your therapist will be happy to help you set up a meeting with another mental health professional for a second opinion
ELIGIBILITY FOR SERVICES
Our services are available to all individuals whether self-pay, insurance or medical assistance is the payer. Our services will not discriminate on the basis of ability to pay, age, gender, race, sexual orientation, creed, religion, disability, or national origin. Prevention, diagnosis, and treatment of mental health are the main purpose of our services. Our team of multi licensed staff are ready to assist you with services or connect you with appropriate referrals.
AVAILABLE SERVICES • Individual, group, couples and family counseling.
If it is our assessment (in an initial intake session) that your treatment needs are outside the scope of services offered at this clinic we will be happy to assist with referral to an alternate mental health provider. At our intake, we will review your concerns and determine with you if our agency is the appropriate fit for your needs or if outside referrals are needed. We may also refer you for further assessment or evaluation. Psychological and Neuropsychological testing services are also available if this is recommended by a mental health professional or Primary Care provider. These services are available for children, adolescents and adults.
There are no eligibility requirements for therapy. People may refer themselves for help or they may be referred by a physician, minister, school principal, physician, attorney, employer, friends or family. Our mental health professionals have expertise in treatment of many mental health difficulties including, but not limited to, the following:
Adult, Adolescent, Child Therapy
Individual, Group, Family Therapy
Marriage, Couples, Life Partner Therapy
Dual Diagnosis (concurrent substance abuse and mental health) Treatment
Alcohol and Drug Abuse Follow-up
Grief and Loss
Custody, Property and Company Issues
Animal Companion Loss
Relationships, Family of Origin Issues
Anxiety and Coping Difficulties
Post-Traumatic Stress Disorder and Trauma Related Problems
Neuropsychological, Psychological, Personality, Intellectual Assessment
Sexual Assault, Sexual Abuse, Sexual Harassment Victim Support and Counseling
Attention Deficit Hyperactivity Disorder
Anorexia, Bulimia, Compulsive Behavior, Overeating, Binge Eating Disorders
Gay, Lesbian, Bisexuality, Transgender Mental Health Issues Adjustment or Phase of Life Problems
• Psychiatric medication management services.
These services are provided by a board-certified Family Psychiatric Mental Health Nurse Practitioner as part of our holistic approach to mental health recovery. Should your medical condition be of complexity beyond the scope of a nurse practitioner you will be provided referral information for a psychiatrist to further evaluate your treatment options. Currently, these services are available for children ages 5 and older and adults.
You are welcome to access our services in our Little Falls or Cold Spring offices.
Counseling - a process by which people who are dissatisfied with some aspects of their lives enter into a relationship with a trained professional to gain greater insight into their situation and to develop more effective ways of responding to life experiences. The function of True Balance Ltd is to help you resolve problem areas in your life. Your therapist will be an understanding person who is interested in helping you work through your emotional distress. It is the function of the therapist to listen, understand, and to be helpful to the fullest extent of his or her professional training. It is your responsibility to help the therapist understand your life situation, thoughts, feelings and to have the courage to try to master problem areas. Counselors do not give advice or make decisions for their clients: rather they ask questions and make comments to help you understand yourself more fully, make your own choices and become more self-reliant. The counseling process may entail emotional pain, stress and life change. Although counseling helps most people, it is not always or completely effective.
Psychiatric medication management – for some people psychiatric medications can play a beneficial role in mental health recovery. This process includes an initial evaluation of psychiatric symptoms and treatment goals, medical history, psychosocial stressors, lifestyle choices, substance use/dependence, and previous medication trials. The provider will also access history of prescriptions that you have filled from other providers in order to ensure that drug interactions are monitored. By participating in medication management services, you are authorizing the provider to obtain external prescription information by any means, including electronic. If it seems that medications may be of assistance the Nurse Practitioner will work with you to create a medication plan that optimizes benefit while minimizing potential adverse medication effects. As with any medication, those medications used for treatment of mental health symptoms carry both the possibility of great benefit and the risk of adverse effects. While your provider will review these risks and benefits with you, it is impossible to predict how any individual will react to a particular medication and it is the patient’s decision which, if any, medications they are interested in utilizing.
• You are able to access medication management through our provider if you are an active participant in therapy (for a minimum of three session prior to service access) or if you have completed therapy with your provider (your provider will need to attest to this) and need to maintain your current prescription.
• Medication for Attention Deficit symptoms will not be prescribed without appropriate psychological or neuropsychological testing.
• Our prescriber may or may not decide to continue your current medications if you choose to transition providers.
• Our prescriber will act within the scope of his or her practice in the prescription of mediations and medication management.
• Our prescriber may need you to complete outside lab work as part of your treatment. This is done at your expense. Failure to complete may result in our prescriber not being able to treat you.
• Our prescriber may recommend that you complete metabolic testing as part of your medication program. This is at your expense.
• Our prescriber may recommend a higher level of care as needed. This can include but is not limited to: Care by a psychiatrist, Care by a specialist team for severe and persistent mental health conditions, Inpatient care, 72 holds, and hospital admission.
Crisis Management Services
Our clinic does offer after hours mental health crisis management services. As part of your mental health treatment plan, community options for mental health crisis management will be discussed on an individual basis.
Pickup and drop-off policies
The True Balance office is not able to accommodate children outside of a scheduled appointment time. Unattended children in the waiting room can represent a safety issue, as no supervision is available during this time. Parents and guardians are asked to arrive no earlier than fifteen minutes before their child’s appointment. You will need to stay the entire time. We do not offer childcare services.
Voluntary Consent to Treatment
You have voluntarily entered into treatment, or give your consent for the minor or person under my legal guardianship mentioned above with True Balance LTD hereby referred as the Center. Further, you consent to have treatment provided by a psychiatrist, psychologist, social worker, counselor, or intern in collaboration with his/her supervisor. The rights, risks and benefits associated with the treatment will be explained. You understand that the therapy may be discontinued at any time by either party. The clinic encourages that this decision be discussed with the treating therapist. Should you file a complaint with a licensing board or compliance board or note to your therapist that you have/will file a complaint, you or your child’s file will be subject to review by the immediate supervisor of the therapist. This will be noted in your client chart.
Non-Voluntary Discharge from Treatment:
A client may be terminated from the Center non-voluntarily, if:
A) the client exhibits physical violence, verbal abuse, carries weapons, harassment of staff or providers, or engages in illegal or grossly unsafe acts at the clinic, and/or
B) the client refuses to comply with stipulated program rules or boundaries, refuses to comply with treatment recommendations,
C) is demonstrating needs outside of the providers competency (at which time appropriate referrals will be made)
D) the provider is no longer able to treat the client due to conflicts of interest, moral conflicts, or treatment is no longer effective or
E) does not make payment or payment arrangements in a timely manner.
F) If you or your child misses 2 appointments in a row or 2 appointments in a 60 day period.
The client will be notified of the non-voluntary discharge by letter and appropriate referrals for continued care will be made. The client may appeal this decision with the Clinic Director or request to re-apply for services at a later date.
Social Media Policy
We do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). Adding clients as friends or contacts on these sites can compromise your confidentiality and respective privacy. It may also blur the boundaries of the therapeutic relationship. If you have questions about this, please bring them up when you meet with your therapist.
You are welcome to view the Facebook Page of True Balance Counseling and read or share articles posted there, but we do not accept clients as Followers of this Page. Having clients as Facebook friends creates a greater likelihood of compromised client confidentiality and it is best to be explicit to all who may view the list of Fans/people who like the page.
Please do not use SMS (mobile phone text messaging) or messaging on Social Networking sites such as Twitter, Facebook, or LinkedIn to contact. These sites are not secure and messages are not read in a timely fashion. Do not use Wall postings, @replies, or other means of engaging in a public online manner if we have an already established client/therapist relationship. Engaging this way could compromise your confidentiality. It may also create the possibility that these exchanges become a part of your legal medical record and will need to be documented and archived in your chart.
If you need to contact your therapist between sessions, the best way to do so is by phone or through our secure online patient portal.
3. Business Review Sites
You may find us on sites such as Yelp, Healthgrades, Yahoo Local, Bing, or other places which list businesses. Some of these sites include forums in which users rate their providers and add reviews. Many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site. If you should find our listing on any of these sites, please know that the listing is NOT a request for a testimonial, rating, or endorsement from you as a client.
Of course, you have a right to express yourself on any site you wish. But due to confidentiality, we will not respond to any review on any of these sites. We urge you to take your own privacy as seriously as we take our commitment of confidentiality to you. You should also be aware that if you are using these sites to communicate indirectly with your therapist about your feelings about your work, there is a good possibility that they may never see it. We hope that you will bring your feelings and reactions to our work directly.
If you do choose to write something on a business review site, we hope you will keep in mind that you may be sharing personally revealing information in a public forum.
4. Location-Based Services
If you used location-based services on your mobile phone, you may wish to be aware of the privacy issues related to using these services. We no longer place our practice as a check-in location on various sites such as Foursquare, Gowalla, Loopt, etc. However, if you have GPS tracking enabled on your device, it is possible that others may surmise that you are a therapy client due to regular check-ins at our office on a weekly basis. Please be aware of this risk if you are intentionally “checking in,” or if you have a passive LBS app enabled on your phone.
Please do not email me content related to your therapy sessions, as email is not completely secure or confidential. If you choose to communicate with me by email, be aware that all emails are retained in the logs of your and my Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. You should also know that any emails I receive from you and any responses that I send to you become a part of your legal record.
You are encouraged to contact your therapist via our secure email system through our patient portal.
Because this is a professional relationship gifts cannot be accepted by mental health providers.
Therapy Animals and Equine Facilitated Therapy
Please be aware that we have a therapy dog in the office on most days. They may greet our clients and hang out in the waiting area, although they spend most of their time with providers and clients in their offices. If you have allergies or are not comfortable with dogs, please inform your provider so appropriate steps may be taken. Therapy dogs are required to be up to date on all their vaccinations.
We also offer Equine Assisted Therapy. Please be aware of the inherent risks associated with work with large animals. We ask you to review the below release of liability.
This RELEASE FROM LIABILITY is made and end entered into by and between TRUE BALANCE, LTD/ True Balance Farm LLC , 16016/15920 233rd Street Little Falls, MN 56345 and any/all officials, directors, owners, and employees associated with the same, hereinafter designated as “True Balance”/ True Balance LTD and Therapy Participant, hereinafter designated “Client.” If Client is a minor, their parent or guardian assumes responsibility for the minor.
In return for the use, today and on all future days, of property, facility, and services of True Balance, LTD, the Client, his/her heirs, assigns, and legal representatives hereby expressly agree to the following:
1. CLIENT UNDERSTANDS THERE ARE RISKS IN AND AROUND EQUINE & PET ASSISTED ACTIVITIES AND TRUE BALANCE LTD, AND THAT TRUE BALANCE LTD IS NOT LIABLE FOR ANY INJURY TO OR DEATH OF A CLIENT RESULTING FROM THE INHERENT RISK OF EQUINE ACTIVITIES AND FACILITIES.
2. CLIENT AGREES TO ASSUME ANY AND ALL RISKS INVOLVED IN OR ARISING FROM THEIR USE OF OR PRESENCE UPON TRUE BALANCE LTD’s PROPERTY AND FACILITY including with out limitations but not limited to: the risks of death, bodily injury, property damage, falls, kicks, bites, collisions with vehicles, horses or stationary objects; fire or explosion, the unavailability of emergency medical care (with the exception of 911), and/or negligence and/or deliberate acts of other persons.
3. Client is responsible for full and complete insurance coverage on his or her horse, personal property, and self.
4. Client agrees to hold True Balance LTD and all successors, assigns, subsidiaries, franchises, officers, directors, owners, employees, and agents completely harmless and not liable and release them from all liability whatsoever and agree not to sue True Balance LTD and all successors, assigns, subsidiaries, franchises, officers, directors, owners, employees, and agents on account of or in connection with any claims, causes, actions, injuries, damages, costs, and/or expenses arising out of the Client’s use of or presence upon True Balance LTD property and facilities including without limitation those based on death, bodily injury, property damage, consequential damages, bodily injury, property damage, falls, kicks, bites, collisions with vehicles, horses or stationary objects; fire or explosion except if the damages are cause by direct and wanton gross negligence of True Balance LTD.
5. Client agrees to waive protection afforded by any statute or law in any jurisdiction whose purpose, substance, or effect is to provide a general release shall not extend to claims, material or otherwise, which person giving release does not know or suspect to exist at the time this release is signed.
6. Client agrees to indemnify and defend True Balance LTD against and hold harmless from any and all claims, causes of action, damages, judgments, costs or expenses, including attorney’s fees, which in any way arises from their use of or presence on True Balance LTD Property or Facilities.
7. True Balance LTD reserves the right to refuse or revoke entry and/or occupancy of any client at any time.
Service animals are permitted in our office by law. Per Minnesota law, service animals are defined as dogs that are individually trained to do work or perform tasks for people with disabilities that are directly related to the person's disability. Service animals are working animals, not pets. A dog whose sole function is to provide comfort or emotional support does not qualify as a service animal. In order to meet the needs of all individuals for whom we provide services, it is the policy of this clinic that all animals other than those meeting the statutory definition of Service Animal are not permitted.
If you would like additional information regarding definitions and rights, please reference the following website: https://mn.gov/mdhr/yourrights/what-is-protected/service-animals/
Records and treatment summaries are maintained for a minimum of 8 years after which time they are destroyed. This time limit begins at age 18 for minors. Our records are stored at our main office in Little Falls and all requests for records should be sent to this location. Upon receipt of a valid written request we will provide a response to your request (within 10 business days). This response may be a call to you, a letter referencing your records and next steps to receive records, or a copy of your treatment summary and/or pertinent portions of your record to another mental health care provider or physician of your choice. If you request release of information to any other entity, we may request personal contact with you in addition to the written release. When release of records creates a safety risk for any individual or entity the law provides for restriction of records release based on an evaluation of the individual situation.
This agency consults and reviews client files. You consent to consultation with therapists inside of True Balance Counseling for the purposes of records audits as required by the state, supervision, and/or case consultation. Consultation will be noted in your client chart and shall include the purpose of the consult/review and what was reviewed in your file.
Client sessions are confidential and we do not allow videotaping or audiotaping of sessions by the client. We will ask for your explicit and writing consent to tape sessions for supervision purposes if needed.
Client Notice of Confidentiality & Limits to Confidentiality:
The confidentiality of patient records maintained by the Center is protected by Federal and/or State law and regulations. Generally, the Center may not say to a person outside the Center that a patient attends the program or disclose any information identifying a patient as an alcohol or drug abuser unless:
1) the patient consents in writing,
2) the disclosure is allowed by a court order,
3) the disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, or program evaluation.
4) To a referring provider as allowed by HIPAA, or
5) To your primary care or collaborating provider as allowed by HIPAA.
Federal and/or State law and regulations do not protect any information about a crime committed by a patient either at the Center, against any person who works for the program, or about any threat to commit such a crime. Federal law and regulations do not protect any information about suspected child (or vulnerable adult) abuse or neglect, or adult abuse from being reported under Federal and/or State law to appropriate State or Local authorities.
Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. It is the Center’s duty to warn any potential victim, when a significant threat of harm has been made. In the event of a client’s death, the spouse or parents of a deceased client have a right to access their child’s or spouse’s records with appropriate legal documentation. Professional misconduct by a health care professional must be reported by other health care professionals, in which related client records may be released to substantiate disciplinary concerns. Parents or legal guardians of non-emancipated minor clients have the right to access the client’s records.
When fees are not paid in a timely manner, a collection agency will be given appropriate billing and financial information about client, not clinical information.
Client data of clinical outcomes may be used for program evaluation purposes, but individual results will not be disclosed to outside sources.
In general, the privacy of all communications between a patient and a psychologist/therapist is protected by law, and we can only release information about our work to others with your written permission, unless as otherwise noted above.
1. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it.
2. There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a patient’s treatment. For example, if I believe that a child [elderly person, or disabled person] is being abused, I must [may be required to] file a report with the appropriate state agency.
3. If I believe that a patient is threatening serious bodily harm to another, I am [may be] required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.
4. Any evaluation, treatment, or reports ordered by, or done for submission to a third party such as a court or a school is not entirely confidential and will be shared with that agency with your specific written permission. Please also note that I do not have control over information once it is released to a third party.
5. All above listed situations and those listed in the following paragraphs.
Case Consultation and Review:
Our therapists often find it helpful to consult other professionals about a case. During a consultation within our agency we may discuss your case in a secure and confidential manner. Our staff meets weekly to discuss cases and gain a more comprehensive view of care, which includes care coordination with our multi discipline team and psychiatric staff. We also conduct inhouse reviews of treatment files yearly. We are legally bound to keep the information confidential. We will document these consultation in ordnance with The Minnesota Government Data Practices Act and Supervisory statutes.
In the case of joint legal custody, it is your responsibility to provide True Balance LTD with a copy of your court order that is in effect. Should you fail to provide this, True Balance LTD will operate under the assumption of joint legal custody with no restrictions or limitations. Minnesota is an assumed joint custody state. The State of Minnesota defines Joint Custody as “both parents share the responsibility for making decisions regarding how to raise the child, including the right to participate in major decisions about the child's education, health care, and religious training.” As such parents are often allowed to seek medical services with the other parent being notified but do have the responsibility to make the other parent aware of services provided to the minor child. The Parent who is consenting to the treatment of their minor child is responsible for notification treatment to the other parent. The Therapist will make every effort to reach out to both parents should contact information be provided and no therapeutic or legal limitations exist. You are responsible for notifying your co-parent of services and appointments and True Balance LTD will not be involved in the resolution of this matter. Please refer to your court order regarding resolution of these differences. It is your responsibility to provide and update your contact information should it change. Should you not provide this information, we may be unable to reach you.
The general goal of involving children in therapy is to foster their development at all levels. At times, it may seem that a specific behavior is needed, such as to get the child to obey or reveal certain information. Although those objectives may be part of overall development, they may not be the best goals for therapy. The involvement of children and adolescents in therapy can be beneficial to their overall development. Very often, it is best to see them with parents and other family members; sometimes, they are best seen alone. Your therapist will assess which might be best for your child and make recommendations to you. Obviously, the support of all the child’s caregivers is essential, as well as their understanding of the basic procedures involved in counseling children.
We will not become involved in legal disputes or other official proceedings unless compelled to do so by a court of law. Matters involving custody and mediation are best handled by another professional who is specially trained in those areas rather than by the child’s therapist.
The issue of confidentiality is critical in treating children. When children are seen with adults, what is discussed is known to those present and should be kept confidential except by mutual agreement. Children seen in individual sessions (except under certain conditions) are not legally entitled to confidentiality (also called privilege); their parents have this right. However, unless children feel they have some privacy in speaking with a therapist, the benefits of therapy may be lost. Therefore, it is necessary to work out an arrangement in which children feel that their privacy is generally being respected, at the same time that parents have access to critical information. This agreement must have the understanding and approval of the parents or other responsible adults and of the child in therapy.
The following circumstances override the general policy that children are entitled to privacy while parents or guardians have a legal right to information.
Confidentiality and privilege are limited in cases involving child abuse, neglect, molestation, or danger to self or others. In these cases, the therapist is required to make an official report to the appropriate agency and will attempt to involve parents as much as possible, with first priority given to the child’s safety and welfare.
Now that the various aspects surrounding confidentiality have been stated, the specific agreement between you and your child/children follows:
1. I agree that there should be privacy in my child's therapy sessions, and I agree to allow this privacy except in extreme situations, which I will discuss with the therapist. At the same time, except under unusual circumstances, I understand that I have a legal right to obtain this information.
2. I will do my best to ensure that therapy sessions are attended and will not inquire about the content of sessions. If my child prefers/children prefer not to volunteer information about the sessions, I will respect his/her/their right not to disclose details. Basically, unless my child has/children have been abused or is/are a clear danger to self or others, the therapist will normally tell me only the following:
a. whether sessions are attended
b. whether or not my child is/children are generally participating
c. whether or not progress is generally being made
3. The normal procedure for discussing issues that are in my child’s/children’s therapy will be joint sessions including my child/children, the therapist, and me and perhaps other appropriate adults. If I believe there are significant health or safety issues that I need to know about, I will contact the therapist and attempt to arrange a session with my child/children present. Similarly, when the therapist determines that there are significant issues that should be discussed with parents, every effort will be made to schedule a session involving the parents and the child/children. I understand that if information becomes known to the therapist and has a significant bearing on the child’s/children’s well-being, the therapist will work with the person providing the information to ensure that both parents are aware of it. In other words, the therapist will not divulge secrets except as mandated by law, but may encourage the individual who has the information to disclose it for therapy to continue effectively.
4. Minors must be accompanied by adults and attended to at all times. True Balance does not assume responsibility for your minor child.
Safe Harbor Agreement
In order to effectuate the stated goal, the parties acknowledge the importance of the therapist’s office being a safe harbor—a place where the children can be truthfully assured that what they say will not be disclosed to third parties without their consent. Per MN Administrative Rules, Chapter 5300.0350, Licensed Marriage and Family Therapist Code of Ethics, Subpart 4, A and C, our therapists are unable to provide ‘belief’ or ‘opinion’ recommendations regarding custody. Your therapist is not a trained custody evaluator.
Agreement. To create the safe harbor for children, the Parties shall agree as follows:
A. Neither parent shall nor will either parent request permission to access the child(ren)’s therapy record or notes of the therapist.
B. Neither parent shall, nor will either parent permit his or her attorney to subpoena the child(ren)’s therapy records or notes of the therapist.
C. This safe harbor agreement does not preclude either parent or his or her attorney from issuing a subpoena to the child(ren)’s therapist for the purpose of having the therapist share treatment goals, impressions, or recommendations with the Court.
D. This safe harbor agreement does not apply to the required disclosures under Mandated Reporting.
E. Any party, or his or her therapist, who seeks to interrogate or subpoena the therapist regarding the content of the child(ren)’s therapy shall be liable for all attorney fees and costs incurred to resist answering discovery requests or to quash any subpoena not consistent with above and will be expected to pay for all of our professional time, including preparation and transportation costs.
Financial Policy and Payment Contract
The Person Responsible for Payment of Account is required to sign this form which explains the fees and collection policies of the clinic (consent) prior to the initiation of services.
Your insurance policy, if any, is a contract between you and the insurance company; we are not part of the contract with you and your insurance company.
As a service to you, the clinic will bill insurance companies and other third-party payers, but cannot guarantee such benefits or the amounts covered, and is not responsible for the collection of such payments. In some cases insurance companies or other third-party payers may consider certain services as not reasonable or medically necessary or may determine that services are not covered.
In such cases the Person Responsible for Payment of Account is responsible for payment of these services. We charge our clients the usual and customary rates for the area. Clients are responsible for payments regardless of any insurance company’s arbitrary determination of medical necessity or of usual and customary rates.
Insurance deductibles and co-payments are due at the time of service. Payments, co-payments, and deductible amounts are due at the time of service. All services that are not paid within 90 days will be sent to collections unless payment arrangements are made. We reserve the right to refuse service for balances over 150.00 if a payment plan is not made. We require payments at a minimum of 30% of the balance due.
Although it is possible that mental health coverage deductible amounts may have been met elsewhere (e.g., if there were previous visits to another provider since January of the current year that were prior to the first session at the clinic), this amount will be collected by the clinic until the deductible payment is verified to the clinic by the insurance company or third-party provider.
All insurance benefits will be assigned to this clinic (by insurance company or third-party provider) unless the Person Responsible for Payment of Account pays the entire balance each session. Your insurance company may not pay for services that they consider to be non empirically based, not medically or therapeutically necessary, or ineligible (not covered by your policy, or the policy has expired or is not in effect for you or other people receiving services). If the insurance company does not pay the estimated amount or refuses services as not medically necessary, you are responsible for the balance.
When fees are not paid in a timely manner, a collection agency will be given appropriate billing and financial information about client, not clinical information. The Person Responsible for Payment will be financially responsible for payment of such services not paid by insurance companies or third-party payers after 30 days.
Payments not received after 90 days are subject to collections. There is a 1% per month (12% Annual Percentage Rate) interest charge on all accounts that are not paid within 30 days of the billing date.
The Person Responsible for Payment of Account agrees to promptly pay invoices. If the Person Responsible for Payment of Account does not, they agree to pay collection costs and attorneys fees incurred to collect payment of overdue invoices and interest allowed by law.
True Balance Ltd does not act as a credit agency. By reading this document and consenting to treatment the Person Responsible for Payment of Account recognizes this and accepts full financial responsibility. The Person Responsible for Payment of Account consents that they are not currently in Bankruptcy proceedings and notes that True Balance Ltd will not be named in Bankruptcy proceedings as a creditor or other party. The Person Responsible for payment of Account waives right to dismiss payment of this account by any Bankruptcy proceeding in any United States State or Federal Court.
Release of Information Authorization to Third Party (Insurance Companies/Payment providers)
In providing your insurance information to True Balance Ltd you are consenting for True Balance Ltd to disclose case records (diagnosis, case notes, psychological reports, testing results, or other requested material) to the above listed third-party payer or insurance company for the purpose of receiving payment directly to True Balance LTD .
In providing your insurance information to True Balance Ltd you understand that access to this information will be limited to determining insurance benefits, and will be accessible only to persons whose employment is to determine payments and/or insurance benefits. In providing your insurance information to True Balance Ltd understand that you may revoke this consent at any time by providing written notice. Failure to provide ongoing insurance information will result in full charges being billed to the patient or custodian.
A cash rate reduction is available for services that are paid ON THE DATE OF SERVICE only.
A sliding fee schedule is available for services. This is based on your proven income. You will need to provide proof of income each month to maintain eligibility for this service. You will need to complete an application and income affidavit prior to services beginning to be eligible for this fee schedule. If you miss or no show an appointment this voids your eligibility for the sliding fee schedule.
Missed appointments or cancellations less than 24 hours prior to the appointment are charged at the rate noted.
Mental Health Counseling Services Fees
Initial Psychological Intake—$325
Individual Therapy (30 Minutes)—$200
Individual Therapy (45 Minutes)—$225
Individual Therapy (60 Minutes)—$250
Family/Couples Therapy(45 Minutes)—$225
Interactive Complexity Add-on—$35.00 (this may be billed in more complicated therapy sessions, including using translation services, EMDR, or play therapy)
Supplemental Psychological Tests—billed on a per test basis
Neuropsychological & Psychological Testing Fees
A fee of $ 250.00 is charged for Psychological Testing (per hour). The fee for testing includes scoring and report-writing per hour. Psychological testing will take place over a period of several days. Charges will be incurred for face to face administration time as well as time to score, interpret and report the results of the administration. Average time for a psychological evaluation is 10-15 hours. The first copy of this report are included in this fee. Subsequent copies will be charged at the subsequent records retrieval rate. Payment for subsequent requests will be due prior to records being released.
A fee of 100.00 is charged for testing materials related to Psychological and Neuropsychological Assessment. This fee will be charged one time for each evaluation and is NOT billable to insurance.
A fee of $ 350.00 is charged for Neuropsychological Testing (per hour). The fee for testing includes scoring and report-writing per hour. Neuropsychological testing will take place over a period of several days. Charges will be incurred for face to face administration time as well as time to score, interpret and report the results of the administration and associated records. Average time for a neuropsychological evaluation is 20-30 hours. The first copy of this report are included in this fee. Subsequent copies will be charged at the subsequent records retrieval rate. Payment for subsequent requests will be due prior to records being released.
A flat fee of 100.00 is charged for testing materials related to Psychological and Neuropsychological Assessment. This fee will be charged one time for each evaluation and is NOT billable to insurance.
Current Fees for Medication Management Service Fees:
Medication management rates are based on Evaluation and Management Coding as mandated for use in 2013 by the American Medical Association and are based on the complexity of factors involved in your care and/or time spent with the provider. Rates range as follows:
New Client: $125.00/$175.00/$225.00/$325.00/$400.00
Established Client: $100.00/$150.00/$200.00/$225.00/$300.00
Court Ordered Services (in conjunction with Balanced Mediation Services LLC)
Court ordered services are Often not covered by your health plan. Services such as Anger Management, Domestic Violence, Parenting Capacity Assessment, and court ordered psychological evaluation are non-covered services. You will be charged a nonrefundable flat fee according to the following schedule:
Anger Management Group (available 6 times yearly): (16 hour) $ 800.00
Domestic Violence Program (available 6 times yearly): (36 hour) $ 1400.00
Parenting Capacity Assessment: $2400.00
Court Ordered Psychological Evaluation: $2500.00 (includes IQ, Personality, and Interview)
Reunification Therapy: 250.00 per hour
A fee of 30.00 per half hour is charged for travel that is not medically necessary.
A fee of 10.00 will be charged as a records retrieval fee and each page will be charged at the rate of $1.32 per page. Requests for records must be made in writing and must include a valid signature (client or guardian).
Other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. These services will be charged in 15 minute increments at the hourly rates of 200.00 for masters level providers and 300.00 for PhD level providers.
Missed Appointment or Late Cancelation Fees
A fee of $ 60.00 is charged for missed appointments or cancellations with less than 24 hours’ notice for mental health therapy/counseling sessions. A fee of $ 140.00 is charged for missed appointments or cancellations with less than 24 hours’ notice for medication management sessions. A fee of $ 100.00 per scheduled hour is charged for missed appointments or cancellations with less than 24 hours’ (late cancel) notice for psychological or neuropsychological testing sessions. If you choose to no show for your scheduled appointment without calling following this policy, all future appointments will be canceled. You may be non voluntarily discharged from therapy should you or your child miss or late cancel two consecutive appointments or miss/late cancel two appointments in a 6 month period.
Court Preparation Fees
A fee of 400.00 per hour is charged for court preparation, legal proceedings, and attendance of such activities. A minimum of 5 hours will be charged and payment in full for the minimum hours (2000.00) will be due prior to court appearance, with the remainder due following appearance as billed. If you become involved in legal proceedings that require your therapist’s participation, you will be expected to pay for that professional time even if the therapist is called to testify by another party. [Because of the difficulty of legal involvement, you will be charged 400.00 per hour for preparation and attendance at any legal proceeding.]
My Primary Insurance Company is:
* . My Insurance ID is: ID number . My Group number is: group number* .
My Secondary Insurance Company is:
. My Insurance ID is: ID number . My Group number is: group number .
I Authorize True Balance Ltd: to charge my card for missed appointment fees, late cancellation fees, the balance of fees denied by my insurance company, or not paid by my insurance company within 90 days of date of service, and insufficient check amounts plus insufficient check fee of $30 per bad check. If I have questions about these charges, I agree to contact True Balance LTD. The charges will be labeled “Services” on my credit card statement not by my provider’s name due to confidentiality. I agree that I will not pursue a refund directly through my credit/debit card company, bank, or financial institution. If any of my actions yield a charge-back for any reason, I agree to pay any and all penalty fee(s) incurred by my provider. I, full name authorize regularly scheduled payments to the below listed payment source for the following client account: First Name Last Name. Signature*
I authorize True Balance LTD to charge the credit card indicated in this authorization form according to the terms outlined above. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this credit card and that I will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.
Your therapy or evaluation session is being conducted during the COVID-19 outbreak. All efforts have been made to provide a safe environment, including: taking the temperature of every therapist that enters the office, questioning each examinee about potential contact with individuals with COVID-19, disinfection of high-contact surfaces and materials after each session, excluding individuals from the waiting room, use of a medical grade HEPA filter in the office and waiting room, use of single-use pens and pencils, and provision of hand sanitizer, masks, face shield and gloves for your use and maintaining social distancing. While these protocols have been implemented to optimize your safety and minimize any possible transmission of COVID-19, safety cannot be guaranteed.
Your participation in services at this facility is voluntary. If you have any concerns or are uncomfortable you are encouraged to reschedule your therapy session or evaluation for a later date, or access your sessions through Tele-Health. Your continued participation in services indicates consent and understanding of the risk.
Federal and state privacy and medical records laws protect your rights as a client of TRUE BALANCE LTD.
This notice applies to your current contact with TRUE BALANCE LTD and all future contacts, whether the contact is in person, by telephone, or by mail.
This notice describes how your medical information may be used and disclosed and how you can get access to this information. Please review it carefully.
This Notice is effective January 1, 2018 and governs our practices on and after that date.
TRUE BALANCE LTD and affiliated businesses are required to protect the privacy of your Protected Health Information (PHI). We are required by the Health Insurance Portability and Accountability Act (HIPAA) to provide you with a notice of our legal duties and privacy practices with respect to PHI. The terms we, our, and us refer to TRUE BALANCE LTD, and the terms you and your refer to our clients.
This Notice of Privacy Practices describes how we may use and disclose your PHI to carry out treatment, payment, and health care operations and for other purposes that are specified by law.
We reserve the right to change this Notice. The changes will apply for PHI we already have about you and PHI we receive about you in the future. We will provide an updated Notice to you when you request one. We will also post the most current Notice at each clinic and on our web site at www.truebalancefarm.com
If you have questions about this Notice, our privacy practices, or the TRUE BALANCE LTD services this Notice applies to, please contact us at the appropriate Contact Office listed on the last page of this Notice.
Protected Health Information (PHI) is:
Information about your mental or physical health, related health care services, or payment for health care services.
Information that is provided by you, created by us, or shared with us by related organizations.
Information that identifies you or could be used to identify you, such as demographic information, address and phone number, social security number, age, date of birth, dependents, and health history.
How TRUE BALANCE LTD Protects Your PHI
Except as described in this Notice or specified by law, we will not use or disclose your PHI. We will use reasonable efforts to request, use, and disclose the minimum amount of PHI necessary.
Whenever possible, we will de-identify or encrypt your personal information so that you cannot be personally identified. We have put physical, electronic, and procedural safeguards in place to protect your PHI and comply with federal and state laws.
You have the following rights with respect to your PHI.
Obtain a copy of this Notice. You may obtain a copy of this Notice at any time. Even if you have agreed to receive the Notice electronically, you are still entitled to a paper copy.
Request restrictions. You may ask us not to use or disclose any part of your PHI. Your request must be in writing and include what restriction(s) you want and to whom you want the restriction(s) to apply. This includes the right to restrict disclosures of PHI to Health Insurance companies when the services provided are paid for in full out of pocket. Any request to restrict specific disclosures to individuals or entities must be made in writing. We will review and grant reasonable requests, with respect to and within the limits of state and federal law.
Inspect and copy. You have the right to inspect and get a copy of your PHI for as long as we maintain the information. You must put your request in writing. We may charge you for the costs of copying, mailing, or other supplies that are necessary to grant your request.
We do have the right to deny your request to inspect and copy. If you are denied access, you may ask us to review the denial.
Request amendment. If you feel that your PHI is incomplete or incorrect, you may ask us to amend it. You may ask for an amendment for as long as we maintain the information. Your request must be in writing, and you must include a reason that supports your request.
In certain cases, we may deny your request. If we deny your request for amendment, you have the right to submit a statement of disagreement with our decision to be placed on file with your records.
Receive a list (an accounting) of disclosures. You have the right to receive a list of the disclosures (an accounting) that we have made on your PHI on or after the initial start and consent to services.
The list will not include disclosures that we are not required to track, such as disclosures for the purposes of treatment, payment, or health care operations; disclosures which you have authorized us to make; disclosures made directly to you or to friends or family members involved in your care; or disclosures for notification purposes.
Your right to receive a list of disclosures may also be subject to other exceptions, restrictions, and limitations.
Your request for an accounting must be made in writing and state the time period for which you would like us to list the disclosures. We will not include disclosures made more that six years prior to the date of your request, or disclosures made prior to April 14, 2003.
You will not be charged for the first disclosure list that you request, but you may be charged for additional lists provided with the same 12-month period as the first.
Request confidential communication. You may ask us to communicate with you using alternative means or alternative locations. For example, you may ask us to contact you about medical records only in writing or at a different address than the one in your file. Your request must be made in writing and state how and when you would like to be contacted.
You do not have to tell us why you are making the request, but we may require you to make special arrangements for payment or other communications.
We will review and grant reasonable requests, with respect to and within the limits of state and federal law.
Special Rules for Psychotherapy Notes. Only psychotherapy notes collected be a psychotherapist during a counseling session are considered PHI. If those notes are kept separate from a client’s medical records, HIPAA requires that they be treated with higher standards or protection than other PHI.
It is not TRUE BALANCE LTD’s practice to keep psychotherapy notes as defined by HIPAA, or to keep any client notes separate from the client’s file.
You have a right to be notified if your PHI is impermissibly released or disclosed due to a breach including theft, loss, or other form of disclosure.
TRUE BALANCE LTD will attempt to contact all affected individuals in the event of a breach at their last known address or contact number.
Limitation on Sale of PHI
TRUE BALANCE LTD may not sell your PHI without your express written authorization for any reason.
TRUE BALANCE LTD does not presently sell PHI of any of our patients for any reason. If this changes in the future, you will be notified in writing and be given the chance to opt out.
When TRUE BALANCE LTD May Use and Disclose PHI
Common reasons for our use and disclosure of PHI include:
Treatment. To provide, coordinate, or manage health care and related services for you to make sure you are receiving appropriate and effective care.
For example, we may contact you to provide appointment reminders, information about treatment alternatives, or to refer you to other health-related benefits and services that may be of interest to you. Or we might contact another health care provider or third party to share information or consult with them about the services we are providing to you.
Payment. To obtain payment or reimbursement for services provided to you. For example, we may need to disclose PHI to determine eligibility for treatment or claims payment.
Health Care Operations. To assist in carrying out administrative, financial, legal, and quality improvement activities necessary to run our business and to support the core functions of treatment and payment.
Business Associates. Our business associates perform some health care administration and operation activities for us. Examples of our business associates include our billing service and claims administrators. We may disclose PHI to our business associates so that they can perform the job we have asked them to do.
We require our business associates to sign agreements that limit how they use and disclose PHI. In addition, business associates are required by law to comply with all HIPAA regulations and requirements regarding the use and protection of your PHI.
Health Plan Sponsor. We may disclose PHI to a group health plan administrator, which may, in turn, disclose such PHI to the group health plan sponsor, solely for purposes of administering benefits provided by TRUE BALANCE LTD.
Individuals involved in your care or payment for your care. We may disclose your PHI to a family member, other relative, close friend, or any person you identify, who is, based on your judgment, believed to be involved in your care or in payment related to your care.
As required by law. We must disclose PHI about you when required to do so by law.
Less common reasons for our use and disclosure of PHI include:
Legal proceedings. We may disclose PHI for a judicial or administrative proceeding in response to a court order, written notice, or protective order. TRUE BALANCE LTD will not release PHI pursuant to a subpoena without a properly completed release of information authorizing TRUE BALANCE LTD to do so.
To avert serious threat to public health and safety. We may disclose PHI to avoid a serious and imminent threat to your health or safety or to the health or safety of others.
Military or national security and intelligence activities. We may disclose PHI to armed forces personnel under certain circumstances and to authorized federal officials for national security and intelligence activities, including protective services for the President and other Heads of State.
To provide reminders and benefits information to you. Disclosures may be used to verify your eligibility for health care and enrollment in various health plans and to assist us in coordinating benefits for those who have other health insurance or eligibility for government benefit programs.
Worker/s compensation. We may disclose PHI to comply with worker’s compensation laws and other similarly legally established programs.
Food and Drug Administration (FDA). We may disclose PHI to a person or company required by the FDA to report adverse events or product defects or problems, track products, enable product recalls, make repairs or replacements, monitor marketing as required.
Public Health. We may disclose PHI to a public health authority that is permitted by law to receive the information for public health activities. This disclosure might be necessary to prevent or control disease, injury, or disability.
Abuse or neglect. We may make disclosures to government authorities or social service agencies as required by law in the reporting of abuse, neglect, or domestic violence.
To government agencies for compliance purposes.
We may use or disclose PHI to the Secretary of Health and Human Services to assist with a complaint investigation or compliance review.
Correctional. We may use or disclose PHI, as authorized by law, if you are an inmate of a correctional facility.
Law enforcement. We may disclose PHI to law enforcement officials for the purpose of identifying or locating a suspect, witness, or missing person, or to provide information about victims of crimes.
Your written permission
We are required to get your written permission (authorization) before using or disclosing your PHI for purposes other than those provided above, or as otherwise permitted or required by law. If you do not want to authorize a specific request for disclosure, you may refuse to do so without fear of reprisal.
You may withdraw your permission
If you do provide your written authorization and then later want to withdraw it, you may do so in writing at any time. As soon as we receive your written revocation, we will stop using or disclosing the PHI specified in your original authorization, except to the extent that we have already used it based on your written permission.
You may file a complaint
If you believe your privacy rights have been violated, you can file a complaint with
HIPAA Compliance Officer
True Balance Ltd
16016 233rd Street
Little Falls, MN 56345
Or with the United States Department of Health and Human Services at:
Medical Privacy Complaint Division
Office for Civil Rights
U.S. Department of Health & Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, DC 20201
Filing a complaint will in no way affect the care or services you receive from TRUE BALANCE LTD.
Why do we ask for information?
We ask for information from you to determine what service or help you need, develop a service plan with you, and give you the services you want.
The information may also be used to determine your charges for services or for collection of payment from insurance companies or other payment sources.
Do you have to give information to us?
There is no law that says you must give us any information. However, if you choose to not give us some information, it can limit our ability to serve you well.
What will happen if you do not answer the questions we ask?
Without certain information, we may not be able to tell who should pay for your services.
What privacy rights do minors have?
If you are under 18, you may request that information about you be kept from your parents. You must give us your request in writing, describe the information, and tell us why you don’t want your parents to see it.
If, after reviewing your request, TRUE BALANCE LTD staff believe that giving information to your parents is not in your best interest, we will not share the information. If TRUE BALANCE LTD staff believe this information could be safely shared with your parents, we will inform you of that decision.
If you are at least 16, you may ask for mental health services without the consent of your parents, but you may have to pay for the services if you do not want your parents to know.
Organizations Covered by this Notice
This Notice applies to the privacy practices of the
TRUE BALANCE LTD.
Complaints: If you have any complaints or questions regarding these procedures, please contact the clinic. We will get back to you in a timely manner. You may also submit a complaint to the US Dept. of Health and Human Services or the MN Board of Marriage and Family Therapy or the MN Board of Psychology.
In signing this Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. We, under current HIPPA Omnibus Rule, provide you this information with your knowledge and consent. This HIPPA Form will serve as authorization until a new form is signed and replaces this form.
My signature below indicates that I understand the limits of confidentiality, privacy policies, my rights, and their meanings and ramifications, and the above listed information on each page of this policy/patient form. I further understand that therapy/evaluation is not successful for everyone and my perception of my life may change for the better or worse based on my participation in therapy and therapeutic interventions. I further understand that my therapist is only able to understand my life based on what I share. Therefore, the success of therapy/evaluation is my responsibility and choice.
Understanding Neuropsychological Evaluation- Informed Consent
You or your child has been referred for a Neuropsychological Evaluation. This form contains information about the evaluation. You will be asked to sign this form indicating that you understand the information provided to you and agree to proceed with the evaluation. If you have any questions please ask before signing this consent form.
This document was created to help you understand the policies and procedures for an evaluation and prepare you for the steps ahead. Please thoroughly review this document, as it contains information that is very important for you to know.
Neuropsychological Evaluation is a process of testing that uses a combination of techniques to help arrive at a hypotheses about a person and their behavior, personality, and capabilities. It is important to know that Neuropsychological Evaluation is not the same as Psychotherapy. Unlike Psychotherapy, Evaluation includes the use of psychological tests that are administered by a Licensed Psychologist, clinical trainee under the supervision of a Licensed Psychologist, or psychometrician under the supervision of a Licensed Psychologist. These tests are standardized, objective, and quantitative. Final evaluation results and interpretation of all testing and measures are provided by the licensed neuropsychologist and/or psychologist.
The goal of this neuropsychological assessment is to determine if any changes have occurred in your cognitive (e.g., attention, memory, problems solving, etc.), emotional, behavioral, and/or physical functioning, and suggest possible methods and treatments for rehabilitation. In addition to an interview where you will be asked questions about your personal background and current medical symptoms, you will be asked to complete various standardized tests (mostly paper and pencil), and asked to fill out questionnaires to assess the nature and extent of any medical and/or psychological problems that may be affecting your current level of functioning.
Nature of Assessment Neuropsychological and psychological evaluation includes a comprehensive evaluation of a person’s intellectual, academic, and/or emotional functioning. Results from evaluations can be used to give opinions and make recommendations concerning diagnosis, treatment, rehabilitation, job or school functioning, ability to drive, ability to live independently, and/or the need for further evaluations. When appropriate, this information can be shared with the individual being evaluated, his or her family members, teachers, or health care providers.
The Neuropsychological Evaluation process takes place in four primary stages:
1. Intake InterviewThe intake interview is conducted between the client and the psychologist. The purpose of this interview is to obtain background information, discuss your concerns, and identify the objectives for the evaluation. This process can take 45 – 120 minutes. This may be completed over one or several sessions.
2. TestingTesting may take place over the course of one or more sessions lasting 1-6 hours per session. The total testing time usually ranges between 4 – 12 hours, depending on the individual needs of the client and the assessments administered. Psychological tests may be administered by a Licensed Psychologist, a clinical trainee under the supervision of a Licensed Psychologist, or psychometrician under the supervision of a Licensed Psychologist.
3. Scoring, Interpretation, and Report WritingYour psychologist will score and interpret the results from testing. In addition, your psychologist may prepare a report depending on your needs. The amount of time dedicated to this process typically ranges from 2-20 hours dependent on the complexity of the case.
This time includes a review of released records. A delay in the receipt of records will delay your results session. Typical response time for the receipt of noncomplex records ranges from 10-14 business days. Complex or lengthy records can take up to one month to receive. Further, these records must be compiled and reviewed as well as integrated into your report which can also be a lengthy process, dependent on the length of records.
This report will NOT be released to outside parties without consent or court order. Your psychologist will review the scores and interpretation of scores with you prior to the release of the report, unless this waived with the understanding that the report may not be accurate.
4. Client/Parent Feedback Meeting Your psychologist will invite you to a feedback meeting to provide interpretation about the testing results, review diagnostic impressions, and discuss treatment recommendations. This meeting will take place about 3-4 weeks after the completion of the above process (dependent on the receipt of outside records and appointment availability for both yourself and the provider) and will last approximately 30-45 minutes.
You will not receive your report at this time as it is not uncommon for new information to be presented in this review session. You will typically receive your report if authorized and your bill is settled within 1-2 weeks following this feedback session (again dependent on the complexity of the case).
In addition to the stages of the Neuropsychological Evaluation described above, other services are sometimes necessary. For example, your psychologist may find it helpful to speak with other professionals involved in your care, or your child’s care. Such professionals can include teachers, physicians, counselors, or other psychologists. For some children, a school observation may be recommended to provide a better idea of how your child is functioning in his or her educational setting. In some cases, your evaluation may include an interview with your closest family member(s) and/or significant other(s). If consultation with outside parties is necessary, you will be asked to sign an Authorization to Release Information form prior to any communication unless communication is allowed under HIPAA.
Child and Adolescent Neuropsychological Evaluations Depending on the child’s age and nature of the concern, the initial intake interview may include a private conversation between the child and psychologist. At this session, consent for treatment will be required from parent(s)/legal guardian(s). Neuropsychological Evaluations will not begin without applicable consents. If any question exists regarding the authority of the representative to give consent for therapy, the psychologist will request supporting legal documentation, such as a custody order, prior to the commencement of services.
Privilege In order for an accurate assessment to be conducted, a safe and private environment must be created for the child or adolescent. Thus, the dialogue and the content of the sessions between the child and psychologist will remain private. Limitations include any instances of safety concerns which will be determined by the psychologist.
Confidentiality Please refer to the Notice of Privacy Practices provided to you at the time of your initial appointment for details regarding privacy information, your rights regarding this information, and situations in which this information may be shared. Overall, it is our goal to ensure the utmost confidentiality of your sensitive personal information. However, there are situations in which we can and in some cases are legally obligated to share your information without specific consent. These situations include but are not limited to:
-danger of harming self or other
- a court order
- parent or guardian of a minor (under 18 years of age) requests information
- concern that an elderly or vulnerable individual is being abused
- suspected child abuse or vulnerable adult abuse
- information shared with third partied (e.g., insurance companies) for the purpose of payment
Pickup and drop-off policies The True Balance office is not able to accommodate children outside of a scheduled appointment time. Unattended children in the waiting room can represent a safety issue, as no supervision is available during this time. Parents and guardians are asked to arrive no earlier than five minutes before their child’s appointment. You will need to stay the entire time. We do not offer childcare services.
Limits of Neuropsychological Evaluation There are many potential benefits to Neuropsychological Evaluations that include diagnostic clarification, individualized treatment recommendations, insight into the nature of your strengths and areas of impact, as well as providing a written report to assist in facilitating services in the community or at school when necessary. Although most individuals have a positive experience during the assessment process, it is always possible to experience discomfort such as frustration, anxiety, or embarrassment. In addition, it is important to know that the results of the Neuropsychological Evaluation may not answer all of your questions about your situation, or your child’s situation. Thus, other referrals may be made to other service providers.
Benefits and Risks Our goals are to document the possible causes of your concerns, provide objective documentation of your current level of functioning, and suggest ways to improve your functioning. Some referral sources have specific questions such as if there is evidence of a disability, evidence of impaired driving, the need for academic accommodations, etc. These questions will be tended to in the final report. There is no guarantee that the evaluation results will help or harm your case if you are receiving compensation or insurance benefits. There is no guarantee that the findings of the evaluation will be in agreement or disagreement with your current understanding of your condition.
It is important that you put forth your best effort and answer questions honestly. Should your test performance suggest you are not putting forth your best effort possible, this can invalidate test results and lead to inconclusive findings. Although you are expected to give your best effort, you are not expected to know the answers to all questions. Some tests will be easy and fun and some will be boring and difficult. Some tests are designed to “test the limits” of your abilities and knowledge and may become increasingly difficult for you. This is a normal experience, but may also cause fatigue, frustration, and anxiety. All reasonable measure will be taken to keep you as comfortable as possible. All we ask is that you try your best and keep us informed of any discomfort or concerns you have as they arise.
The Therapeutic Relationship The relationship between you and your psychologist is unique. You will be sharing information with your psychologist that may be sensitive and intimate. It is not your psychologist’s job to make judgments or give advice. Rather, the psychologist’s role is to understand your concerns and take this into consideration when formulating treatment recommendations. It is important to know that Neuropsychological Evaluation is not Psychotherapy. Completion of testing does not imply an on-going psychotherapeutic relationship with your psychologist, unless such a relationship has been specifically and mutually agreed upon.
You are encouraged to be honest with your psychologist about your feelings and history. This is the best and safest way to cultivate a stronger sense of self and an effective working relationship. Any opinion, conclusion, diagnosis, or recommendation will be based upon the information contained and referenced from the sources indicated, including the self-report from the subject of the evaluation. Substantial inaccuracies with the information reported could affect the validity of the results and conclusions of this evaluation. The report will not be edited once complete unless the information provided to the clinician substantially affects the diagnosis and ONLY at the clinicians decision. At that time, the information will be added to an addendum.
The evaluation may result in a diagnosis that you or a member of your family may not agree with. It is possible that you may not agree with the results of this evaluation or the information contained in this report. This evaluation is based on the information and procedures listed below as interpreted by this evaluator.
Fees for Services:
A fee of $ 250.00 is charged for Psychological Testing (per hour). The fee for testing includes scoring and report-writing per hour. Psychological testing will take place over a period of several days. Charges will be incurred for face to face administration time as well as time to score, interpret and report the results of the administration. The first copy of this report are included in this fee. Subsequent copies will be charged at the subsequent records retrieval rate. Payment for subsequent requests will be due prior to records being released. You will be financially responsible for services if denied as not medically necessary by your insurance company.
A fee of $ 350.00 is charged for Neuropsychological Testing (per hour). The fee for testing includes scoring and report-writing per hour. Neuro psychological testing will take place over a period of several days. Charges will be incurred for face to face administration time as well as time to score, interpret and report the results of the administration and associated records. The first copy of this report are included in this fee. Subsequent copies will be charged at the subsequent records retrieval rate. Payment for subsequent requests will be due prior to records being released. You will be financially responsible for services if denied as not medically necessary by your insurance company.
A fee of 30.00 per half hour is charged for travel that is not medically necessary.
A fee of 17.54 will be charged as a records retrieval fee and each page will be charged at the rate of $1.32 per page. Requests for records must be made in writing and must include a valid signature (client or guardian).
A fee of $ 40.00 is charged for missed appointments or cancellations with less than 24 hours’ notice. If you choose to no show for your scheduled appointment without calling following this policy, all future appointments will be canceled.
Billing Agreement Regarding Insurance Reimbursement
At times, insurance companies do not fully reimburse psychological or neuropsychological testing services, whether your clinician is an in-network or out-of-network provider.
There are two main situations when this occurs: 1) the insurance company does not consider psychological testing “medically necessary” for “experimental” or “investigational” diagnoses. Diagnoses considered “experimental” or “investigational” vary depending on the insurance carrier. Another situation is 2) when insurance companies reimburse fewer hours than billed. For example, some insurance companies only reimburse up to 12 hours of psychological testing, whereas 15-20 hours are typically billed for a full evaluation.
It is your responsibility to verify coverage with your insurance company prior to consenting to services. While we make every effort to verify benefits and coverage and obtain authorization for services prior to beginning services, you are ultimately responsible for knowing your coverage and for all charges. Please let us know if you have questions or concerns in this area.
Most insurance companies require that you be informed of the reason testing hours or services were denied or deemed not medically necessary. Below are listed several potential reasons.
-Testing services are considered “experimental” or “investigational” for the diagnosis
- Educational/Academic testing is not typically covered under your plan
- Psychological testing requires a pre-authorization or referral
- Psychological testing is covered only up to a certain number of hours
Your signature on the Neuropsychological consent indicates that you have read this document and agree to pay for all psychological/neuropsychological testing and evaluation services, even those not reimbursed by your insurance carrier. You are indicating that you understand and agree to the information above. You are agreeing to be “balance billed” for any hours not approved or reimbursed by my insurance company, whether in-network or out-of-network, for services rendered by True Balance Ltd. Your signature indicates that you have called to verify coverage for services with your insurance carrier. If you did NOT call to verify coverage, then you choose to proceed knowing that services may be denied and that you will be billed for these services.
I understand that the full psychological or neuro-psychological report will not be released until my account is paid in full. Progress notes for each session and the final diagnosis are available to insure that access to medical care is not restricted.
Your signature below indicates that you have read this document and agree to pay for all psychological/neuropsychological testing and evaluation services, even those not reimbursed by your insurance carrier.
My signature below indicates acceptance of the above policies and procedures.