• HWCGP: Parent Informed Consent + Policies Form

    HWCGP: Parent Informed Consent + Policies Form

    Policies & Procedures of Behavioral Neuropsychology, LLC [BN, LLC]
  • This form contains 1] Policies & Procedures of the Homework Coaching Program [HWCGP]; 2] your rights and responsibilities as a parent/consumer of HWCGP, 3] confidentiality & privilege issues; 4] a HIPAA summary [law providing protection of patient information when a health-related organization uses/discloses Protected Health Information [PHI] for treatment, payment, or clinic operations. Please read this carefully, and ask questions if you do not understand or if it is unclear. 

    Page 1 Overview

    Page 2 Parent & Student Information   

    Page 3 Homework Coaching Policies & Procedures 

    Page 4 Informed Consent, Confidentiality, & HIPAA for HWCGP

    Page 5 Fees, Fee Policies, Credit Card Information  

  • Parent Information


  • Homework Coaching Student Information

  •  / /
  • Policies & Procedures 

    • Scheduling: Our HWCGP is conducted in your home, or at a place you and your homework coach mutually agree upon, or less often via a secure vitual link [we set up and provide to you].
    • Hours are negotiated between you and your HWC but are not regularly scheduled later than 9 PM M - F.
    • Weekend times are available for some situations and some HWC's by arrangement.

    Homework Coaching involves mainly modeling, executive skills training, and self-management. Major goals: The Homework Coaching program is intended to help students learn to use homework time so they get more work done in less time (maybe even some time left to relax!) and eventually to help students fade the homework coaching so they can work at the same level of effectiveness on their own. And through this process, students will:
    < Learn how to figure out what works and what doesn't through developing a trial and-error process (identify problems instead of hiding them; brainstorm solutions and try them out instead of sticking with what doesn't work).
    < Take charge of their own learning (increase self-awareness of their own strengths and challenges; increase activation as students; see themselves as agents, in charge of the learning process, knowing what they need and getting it to happen) .

    • If your student is under 18, a parent or designated responsible adult [>21 years of age] is expected to be home at all times the HWC meets with your student.
    • Homework coaches schedule and charge for session unless an exception has been arranged at least 24 hours ahead of time, or a family emergency occurs. 
    • HWCG sessions are scheduled in advance on a regular/convenient basis for you and your student with your homework coach. 24-hour advance notice is required if your student is unable to keep an appointment. If you DO NOT give 24 hours notice you will be charged for the full session. Depending on the coach's discretion, it sometimes is possible to reschedule that session within the same week without charge, though only on a case by case basis, and if your homework coach is able to arrange.
    • To cancel any session 24 hours in advance, call or email your Homework Coach.
  • HW Coaching Policies & Procedures 

  • Your HW Coach [HWC]

    • Your HWC is a graduate student in a doctoral or master's clinical psychology program unless otherwise noted. Your HWC works under the scope of practice of Antonia Forster, PhD, ABPP; Michael Fulop, PsyD, and Alisa Karmel, PsyD. Dr's Forster and Fulop are Oregon licensed psychologists and Dr Alisa Karmel is a post-doctoral-psychology-resident [supervisor Michael Fulop]. Dr. Karmel is the clinical director for our HWCGP, and one of the most experienced frontline homework coaches. Hayden Forster is our assistant director, and also one of the most experienced homework coaches. 
    • HWC's are selected for relevant experience. When selected they are trained by our team to work within our Homework Coaching framework. In addition to supporting your student's goals, your HWC will aim to build your student’s persistence with academic work, and develop those executive skills required for planning and follow-through when faced with simple to complex, short or long-term academic projects.
    • It is highly likely your student will develop a strong rapport with their HWC. However, the HWC's role is not designed to be a counselor, therapist, parent, teacher, tutor, babysitter, or deputy from "the homework police." Further, they are not someone that will coerce, cajole, or in any way force your student to complete work. We know from research literature and our experience that student's autonomy to make choices must be validated. Your student will respond more and build more skills within a collaborative and positive relationship.   
    • HWCGP Process: Some students enrolling in the HWCGP have been previously assessed by Dr. Forster or Fulop before meeting their HWC's. For those prior-assessed students starting HW Coaching, you will complete some paperwork, and we will let you know if there are other tests/forms you or your student need to complete.
    • The next step is to complete the HW Coaching Background Questionnaire. Once this is completed, you and your student will schedule a time to meet with Dr. Karmel or Hayden Forster to an Onboarding session. During this session you will discuss your concerns, your goals, and to find out what's been tried, and for your questions about the HWCGP sessions or processes. Following this, Dr. Karmel will match your student with a coach and the coaching can begin!
  • Informed Consent, Confidentiality, & HIPAA for HWCGP

  • Oregon and Federal laws require that issues discussed in therapy, consultation, or for the purpose of diagnosis or coaching with a psychologist or their associates, remain confidential. Generally, any issue you or your family members discuss will not be disclosed to anyone without your permission, however, there are some exceptions. You can waive the doctor-student privilege for specific purposes if and only if you sign a release of information [Authorization form for HIPAA, ROI. We will note all consultations in your homework coaching record [called “PHI”] in a Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information].

    Release of confidential information may ethically or legally be required if child abuse [sexual, physical, emotional], harm to another person, or intent for self-harm is disclosed by a student or patient. Also, if you are involved in a custody proceeding, some courts may have the right to subpoena material from the coaching records. Please ask about any questions you have about the limits of confidentiality for the HWCP.

    BN,LLC employs administrative staff, and with HWCGP interventions there is a need to share protected health information [PHI] with individuals, agencies, or businesses for administrative reasons, such as billing or compliance. Our administrative staff are bound by the same rules of confidentiality, and receive training about privacy protection. Each staff member has agreed not to release information outside of our practice without permission of a professional staff member and only with ther proper release of information. HIPAA requires we have formal associate contracts with administrative staff, and have signed and promised to maintain confidentiality except when specifically allowed or required by law to release PHI.

    HIPAA allows PHI also to be released for the following reasons: 1] A court proceeding; 2] if a government agency requests information for health oversight activities; 3] if complaints or lawsuits are made against BN,LLC staff to share relevant information; 4] disclosures required by insurers or for collection or overdue fees as described elsewhere; 5] if a child abuse, elder abuse, or domestic violence investigation occurs, laws require that BN,LLC staff provide relevant student records to the appropriate government agency. Once such a report is filed, BN,LLC may be required to provide additional information; 6] Consistent with HIPAA 45 C.F.R. §164.512(d), OBOP [Oregon Board of Psychology] is authorized to review, use, or disclose individually identifiable health information as for health oversight for activities authorized by law, including civil and administrative investigations for oversight of individuals/entities subject to government regulation.

    Professionals Records: You should be aware that, pursuant to HIPAA, BN,LLC keeps PHI about the student in two separate professional records. One set constitutes your student’s HWCGP Record, and is information about why you sought HWCGP, a problem description, diagnoses, HWCGP goals, progress, medical and social history, history of treatments, records received from others, billing, and sent reports. These are kept at the offices of BN, LLC. You may examine and receive a copy of your student’s record if requested in writing, except in unusual circumstances that involve danger to your student. Since they are professional records, they might be misinterpreted and might be upsetting to an untrained reader. For this reason, BN, LLC recommends you review only in the presence of either one of our psychologists, or have them forwarded to a qualified mental health professional to discuss the contents and avoid any misinterpretation. If your request for access to your clinical record is refused, you can ask for a review. BN, LLC also keeps brief HWC session notes for HWCGP use. These notes are to assist your student with quality services and for supervision of HWC's. After each HWC session, HWC's makes notes in secure data base, and contents of these sessions vary. They can include summaries, work time completed, work new skils, avoidance patterns, or student goals. Notes do not generally include sensitive information required to be included in formal clinical records. HWC notes are separate from any clinical record that may exist about your student. No one receives a copy of your student’s HWC session notes without a parent's signed authorization except for staff of BN, LLC for supervision or training purposes. HWC session notes can be viewed unless BN, LLC judges doing so would be harmful to your child or teen. 

    Any PHI, if disclosed, may become part of the system, or another agency's files and likely are stored within their computer systems. Though all agencies and entities claim information is kept confidential, BN, LLC has no control over agency's or entities of the information once it has been disclosed. In some cases, a school, insurer, or other stakeholder might share your information with national information data banks. HIPAA provides you with several expanded rights to your Clinical Record and disclosures of PHI, and includes

    • Requesting we amend your record,
    • Request restrictions on information from record is disclosed,
    • Request an accounting of disclosures of PHI you have not consented to or authorized,
    • Determine where PHI disclosures were sent
    • Having complaints you make about policies/procedures recorded in the records,
    • The right to a paper copy of this agreement, notice form, & privacy policies/procedures.     

    We will discuss any issues with you if requested, and we will provide you a copy of this agreement. This summary of confidentiality rights and expectations may be helpful, but it is important that you ask questions or voice your concerns, as the laws governing confidentiality are complex, and we are not purporting to be legal experts or attorneys.

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  • Fees & Fee Policies for Homework Coaching

  • HOMEWORK COACHING SERVICES are not billable to your insurance provider. It is important to remember that you are responsible for your entire bill. It is your responsibility to arrange alternative plans in the event you cannot pay your bill as agreed. Written notices are sent to you for past due account balances; with no response for 90 days your account may be turned over to a collection agency. You will be held responsible for any additional legal and collection agency fees in collection of the account.

    Homework Coaching

    • HW Coaching fee's all purchased in advance
      • Onboarding Fee .........................................$300.00 [including onboarding paperwork, tests, and 1st interview.]
      • 1 hour of Homework Coaching......................$ 50.00  [homework coaching]
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