CONSENT TO TREAT AND DISCLOSURE STATEMENT

Clients Name

Clients and legal guardians consent to receive assessment and/or treatment services at
PranaMind: Functional NeuroPsychology, LLC., and to enter into the following understanding:

Clients will be administered diagnostic and/or treatment procedures recommended by professional staff. In the case of conservatorship, the conservator will need to sign and date this document.

The information provided during assessment and/or treatment services is confidential. Specific information is release to outside agencies or persons only after written consent of the individual or conservator is obtained. The only exceptions to confidentiality are as follows:

• When a client, family member, or collateral person states an intention to seriously harm him/herself or harm another person, PranaMind has the legal obligation to warn the individual’s family, intended victim, and/or police.
• When there is a reason to believe there is abuse or neglect of a vulnerable adult, the law requires a report be made to the police or other appropriate county agencies.
• When an emergency condition occurs, PranaMind will communicate with family members or other appropriate persons
• By court order

The individual or conservator has the right to access clinical information. You may request an information review with a PranaMind practitioner. However, in certain circumstances, if a PranaMind practitioner determines that reviewing such information may be deemed harmful, the practitioner may instead provide a summary of the clinical information.

Fees and financial arrangements will be discussed by the first appointment and a financial agreement will be signed at the onset of the services. When pursuing an evaluation, the total fee is due at the first visit. Scheduled appointments require a 24-hour cancellation notice. If notice is not received, clients may be charged a fee of $150. If an evaluation is cancelled after the full payment has been received, the full payment, less the intake fee and/or any cancellation fees for missed appointments, will be refunded.

It is understood that PranaMind does not bill insurance companies directly and each family is responsible for pursuing their own insurance reimbursement for services.