Edward Jacobs, Ph.D. & Associates
12 Parmenter Road
OFFICE POLICIES AND CONSENT TO TREATMENT AGREEMENT
policies have been established to make psychological services as effective as possible, to minimize the possibility of any
misunderstanding, and to comply with certain legal requirements. Please read this thoroughly, and discuss any questions with
License and Code of Ethics
I am a New Hampshire Licensed Psychologist
(Edward Jacobs, Ph.D., Richard Shulik, Ph.D., Chet Lesniak, Ph.D.) ◊ Independent Clinical Social Worker (Vicki Jacobs,
MSW, Madeleine Mandelbaum, MSW) ◊ Clinical Mental Health Counselor (Danielle Viola, M.A., Robert Mattia, M.Ed., CAGS),
governed by the Code of Ethics of the American Psychological Association (Edward Jacobs, Ph.D., Richard Shulik, Ph.D., Chet
Lesniak, Ph.D.) ◊ National Association of Social Workers (Vicki Jacobs, MSW, Madeleine Mandelbaum, MSW) ◊ American
Counseling Association (Danielle Viola, M.A., Robert Mattia, M.Ed., CAGS). My license, or a current copy of it, is displayed
in these offices. A copy of my professional Code of Ethics is available in these offices for you to review at your request.
Qualifications and Scope of Practice
I received my graduate degree in the
year 1981 (E. Jacobs), 1979 (R. Shulik), 1981 (V. Jacobs), 1983 (M. Mandelbaum), 1991 (R. Mattia), 1999 (D. Viola), 1990 (C.
Lesniak). My practice is a general mental health practice that includes counseling, psychotherapy, and assessments with children,
adolescents, adults, families and groups, as well as consultation with agencies, organizations, and other professionals on
mental health matters. There might also be times when I testify in court as an expert witness. Psychologists also have training
and experience in psychological testing. Neurofeedback training is part of the practices of Edward Jacobs, Ph.D., Richard
Shulik, Ph.D. and Danielle Viola, M.A.
A copy of the
Mental Health Bill of Rights is posted in the waiting area or, if you are seen outside of the main office, will be provided
Nature and Limits:
between you and me, as your psychotherapist, is confidential, and will not be revealed to any other person or agency without
your permission, unless under certain special circumstances. In order to obtain your permission to release confidential information,
I will ask for your permission in writing to release information to a specified person or agency. That permission will have
a time limit to it, and may be revoked at any time by you.
Recognizing the benefit of second opinions, I may
occasionally consult with a colleague about my work, always protecting the identities of my clients.
also certain situations in which I would be legally or ethically required to reveal information obtained during therapy to
other persons and/or agencies without your permission. These situations are as follows: 1) If you communicate "a serious
threat of physical violence against a clearly identified or reasonably identifiable victim or victims" or property, I
am required by law to warn the intended victim(s) or the police, or to obtain civil commitment of you to the state mental
health system; 2) If you indicate a danger of hurting yourself and refuse to accept further appropriate treatment, I may call
your family, agencies, or other individuals who, in my opinion, would assist in protecting your safety; 3) If I have any reason
to suspect that a child or incapacitated adult has been abused or neglected, I am required to report this to the appropriate
state authority; 4) If I am aware of the existence of certain occupationally related illnesses, communicable diseases, or
critical health problems, I must report this to the appropriate state agency. The law prohibits me , except under very limited
circumstances, to disclose the identity of a person tested for the HIV virus; 5) If you are involved in a civil commitment
proceeding, in pursuing a personal injury action, or in filing a workers' compensation claim, or if my conduct is being reviewed
by licensing authorities, your privileged communication may be waived; 6) If I am issued a court order to provide information,
I will be required to comply with that order; 7) If you have a serious or chronic mental illness, a person living with or
providing care to you may be provided information concerning diagnosis, admission to or discharge from a treatment facility,
functional assessment, prescribed medications and side effects, manifestations of the failure to take medications, treatment
plans and goals, and behavior management strategies; 8) If you are subject to an involuntary emergency psychiatric admission,
I might be required to provide information essential to your care; 9) If your treatment is related to an injury from a gunshot
wound or other serious injury suspected to be caused by a criminal act, I might be required to inform a law enforcement official.
Third Party Billing:
If you give me permission to bill a third party for my services,
I will release information to that party necessary for the processing of that claim. If you choose to use your insurance coverage
for my services, most insurance agreements require you to authorize me to provide a clinical diagnosis, and sometimes additional
clinical information such as a treatment plan or goals, or a summary, or copies of reports, or in some cases, a copy of the
entire record. This information will become part of the insurance company files and some of it will probably be computerized.
You have the right to restrict disclosure of encounter information to your insurer if services are paid for out of pocket.
Sometimes information might be exchanged between myself,
my clients, or other entities that is transmitted electronically, such as in the form of faxes, emails or electronic billing
information. I will make every effort to safeguard the confidentiality of this information. Information that is sent by me
will only contain the minimal necessary information to accomplish its purpose. Information that is received by me will be
placed in your chart. Since computers can maintain information on their hard drives even when files have been deleted, and
since I have no control over the way in which other persons or organizations use or store the information that they send to
or receive from me, and since not all email and fax transmissions are encrypted, I cannot guarantee the confidentiality of
this information. If you do not consent to electronic communications, please inform me immediately, before beginning treatment,
so I can determine how to proceed. If you email or fax information to me, or if you request information from me that is emailed
or faxed, it is with the understanding that this information may not be encrypted and may be stored by other parties.
Individuals also have the right to request electronic copies of information that is held electronically.
You have the
right to be notified in the event of a breach of the privacy or security of your Protected Health Information.
Length of Appointments
I will normally make 45 minutes available for your appointment
from the scheduled start of your appointment time. At times I may elect to extend the length of the appointment. I may also,
by mutual consent, agree to meet for briefer periods of time. I am normally available to you during our scheduled appointment
If you need to reach me in an emergency, you
can call my answering service (644-6232) at any time and ask them to try to contact me. The answering service will try to
reach me, and when they do reach me, I will attempt to return your call as soon as possible. PLEASE NOTE: If
you choose to set up your telephone line so it will not accept blocked calls, I might not be able to reach you in an emergency
if I am out of the office, since the telephones that I use outside the office might have blocked numbers.
go about my normal routine during evenings and weekends, and I am out of the office at various times during the week. Since
I do not carry a beeper, and may be unreachable immediately at times, there may be times when it will take me several hours
to return your call.
If you or your family feel that there is an emergency or impending crisis and I cannot
be reached soon enough, contact or go to your nearest hospital's emergency room for assistance.
After evaluating your situation, I will discuss with you my clinical impressions, and
my recommendations for treatment, and decide with you which services are appropriate.
Length of Treatment:
The length of treatment varies according to the needs of each individual client. In many instances,
a client's goals can be accomplished with short-term treatment. In other situations, it may be desired by the client or recommended
by me, that treatment proceed over a longer period of time. It is important to understand the limits of your insurance coverage
and your own financial resources so you can make an informed decision about the affordability of treatment. Many reimbursement
plans are oriented towards a short-term treatment approach, which is often appropriate. However, if a length of treatment
is desired by you that is longer than your insurance company approves, it is important to understand what your financial obligations
Benefits and Risks:
Obtaining psychological services, such as counseling
or psychotherapy, can have benefits and risks. Since participation in these services often involve discussing unpleasant
aspects of your life, you might experience uncomfortable feelings like sadness, anger, guilt, anxiety, anger, frustration,
loneliness and helplessness. On the other hand, obtaining psychological services has also been shown to have benefits for
people. It can lead to better understanding of oneself, better relationships, solutions to specific problems, and significant
reductions in feelings of distress.
Neurofeedback training also can have benefits
and risks. Since we are working with the ability of the nervous system to regulate attention and emotional control, an individual
might respond with feelings of anxiety, sadness, too much energy, too little energy, an excess of emotional expression, a
decrease in emotional expression, or changes in sleep. These effects tend to be temporary and, if they occur, need to be communicated
as soon as possible to your therapist so corrections in the training can be made. The benefits of neurofeedback can include
improved attention, improved processing of information, and improved emotional stability and control.
testing can be used to evaluate your intellectual, cognitive, emotional and personality functioning. The benefits
include obtaining information about yourself or your child about strengths and vulnerabilities, which can also help you plan
for personal, educational, vocational, psychological and parenting matters. Testing can also elicit feelings of sadness or
anxiety, from finding out about problems about which one was unaware, or confirming problems that one suspected were there.
In addition, psychological testing is often sought out or used for specific purposes, such as informing decisions regarding
child custody, educational planning, or eligibility for benefits. The results might not support the outcome that you wish,
and you might experience anger or disappointment.
It is important to understand that the tester must base his
or her conclusions on the information contained in the tests, the patient's history and demeanor, and the tester's clinical
judgment, rather than on a need to please the patient or obtain a certain outcome. It is our policy to change the content
of our psychological testing reports only under rare circumstances, such as to correct factual errors, further clarify clinical
impressions, or protect someone from serious harm.
I maintain a file for each client. The file includes information related to intake, diagnosis,
treatment plan, billing, consent to treatment, treatment notes, and any other written or electronic information I received
from or about the client. Treatment notes include the date of each session and might include information about facts or issues
discussed, and treatment recommendations. The client is entitled to a copy of the records for a fee which covers copying and
administrative costs. The client can also see a copy of the records. If you wish to review a copy of your record, I recommend
that you review it with me so we can discuss its contents.
Release of Records:
am able to release your records, or any part of them, with your written permission, provided you pay for any reasonable copying
or administrative costs in advance. Furthermore as a condition of hiring our services, you agree that records or reports will
not be released to you or other parties if you have an outstanding balance in your account with the practice.
Caretaking of Records in the Case of Incapacity;
In the event of the incapacity or death of
a clinician in this practice, your records will be managed by either Edward Jacobs, Ph.D. or Vicki Jacobs, MSW.
The treatment of a minor must be authorized by a parent or guardian (with
limited exceptions). In the treatment of minors, parents (even non-custodial parents) have the right to access and authorize
release of information. In order for me to be effective in working with a minor, however, the minor needs to have some degree
of privacy in order to trust me and to talk about what the most important concerns.
Therefore, if you are a
parent of a minor who is receiving services from me, you agree that the information that I reveal to you about the minor will
be limited to information necessary to preserve the safety of the minor and others, and information that, in my opinion, will
help you to be helpful to the minor in the context of your relationship with him or her. You agree that it will be at my discretion
to reveal specific content from my meetings with the minor.
records of couple's sessions contain sensitive information about each person. Therefore, in the case of couples treatment,
whether the members of the couple are married to each other, unmarried, separated or divorced, both members of the couple
agree that records will only be released by joint consent. In the event of a disagreement, the records will not be released
without a court order.
Unlike individual treatment, group
therapy is not protected by law. Client concerns about confidentiality should be discussed prior to beginning treatment.
Professional Boundaries and Sexual Misconduct
Licensed psychotherapists are
obligated to establish and maintain appropriate professional boundaries (relationships) with present and past clients and
their family members.
Sexual relations by a mental health professional with a client or a former client (a person
who was given psychotherapy within two years prior to sexual relations with the psychotherapist) is considered sexual misconduct
and is subject to disciplinary action.
Billing and Insurance Coverage
My billing rate is $250 for initial appointments, $215 per 45 minute session, and $215
per 45 min for related work. Related work includes, but is not limited to, telephone consultations; my attendance at meetings
on your behalf, with your consent, including travel time; review of records or files; and the preparation and writing of reports.
Neurofeedback self-pay fee is $140 per half-hour training session. The fee for a quantitative EEG is $950. In cases
of unusual financial hardship, I may be willing to negotiate a reduction in fee.
Payment for services is due
at the time of service or, in the case of related work, upon the receipt of a bill for my services. At times, I require pre-payment
for my services.
Under certain circumstances, I may agree
to bill your insurance directly for my services, with the exception of related work and missed appointments (see below), which
are generally not covered by insurance benefits. If your insurance or other third party is billed for my services, you are
still ultimately responsible for payment of all fees, unless there are exceptions to this provision in my contract with the
insurance company or third party. As stated earlier, it is important to understand the limits of your insurance coverage and
your own financial resources so you can make an informed decision about the affordability of treatment.
client, you agree to an insurance waiver stipulating that any fees that are not paid by your insurance company within 90 days
of billing will be billed directly to you, and that you will be responsible for payment of the claim.
responsible for finding out exactly what services your insurance policy covers, including deductibles, copayments and coverage
limitations. Many insurance companies and managed care plans also require advance authorization before they will provide reimbursement
for services. You are responsible for finding out the services that have been authorized, the number of sessions or hours,
the time limitations, and the authorization number which is necessary for billing. It is your responsibility to keep current
with this information so you know when your authorized coverage will expire. If you do not find out or provide the information
which is required of you, you agree to be fully responsible for payment of my full fee for these services.
addition to the "related work and missed appointments," that are stated above, there are other services that I might
provide that either might not covered by, for which I will not bill to your insurance company. These services include, but
are not limited to, neurofeedback training and some types of psychological testing. The lack of insurance reimbursement available
for these services will be discussed with you, when appropriate. In order to receive these services, you agree to waive insurance
billing and to pay for them directly.
Monthly Statements and Payment:
If you have a balance due, or if you request
it, you will be provided with a monthly statement of your account. All outstanding balances are due upon receipt of the statement,
unless another arrangement has been agreed upon. You agree to have unpaid balances billed to your credit card if other payment
arrangements cannot be made.
For checks that are returned to us for insufficient funds, you will be assessed
a returned check fee of up to $25.
If you are having some
difficulty making payment because of your financial situation, it is important to let me know immediately so we can work out
some plan or timetable for payment that will be manageable for you. As long as you communicate with me about your situation,
I am confident that we can work out a reasonable arrangement for payment.
If your account is more than sixty
(60) days in arrears, and suitable arrangements for payment have not been agreed to, I reserve the option of referring your
account to a collection agency or an attorney to pursue collection of the unpaid balance. If such action is necessary, the
costs of bringing that action or securing that collection will be billed to you, which will be an additional 35% of the balance.
If an outstanding balance remains in your account after you have left therapy, I will make a reasonable effort
to contact you, usually by mail, to arrange payment. If you are unable to pay your balance in full at that time, I will be
happy to work out a payment plan with you at your request. However, if after reasonable efforts to collect from you have failed,
I reserve the option of referring your account to a collection agency or an attorney to pursue collection of the unpaid balance,
and to bill you for the costs of bringing that action or securing payment.
Payments can be made with Visa and
Appointment times are reserved for you
to the exclusion of anyone else. If you cancel or miss your appointment time, for any reason, you will be billed directly
for my full fee, not the fee that I might have contracted for with your insurance company, which only pertains to services
which I provide that is covered by the insurance company. This fee cannot be billed to your insurance or
other third parties. Your signature indicates your agreement with this policy.
for missed appointments is not intended to be punitive. My income depends on my being able to use my available time. I have
promised that hour to you and, if it is not used by you, and I cannot make use of it, I cannot make it up.
try to be as flexible as possible with this policy and, therefore, there are certain exceptions. You will not be charged for
a missed appointment: 1) If you cancel your appointment ahead of time and we can reschedule your appointment during the same
calendar week; 2) If you cancel ahead of time and I can fill the time by scheduling another client in that time. If you cancel
and cannot reschedule, I will make every effort to fill the time with another client; 3) If you are taking a vacation and
inform me at least several weeks in advance; 4) If you or your child is ill and this illness prevents your attendance at our
Complaints and Privacy Inquiries
Reports of professional misconduct
should be directed to the New Hampshire Board of Psychology, 129 Pleasant Street, Concord, NH 03301, (603) 271-9369.
Complaints regarding the privacy of confidential information, the policies and procedures of this practice, or professional
behavior within this practice, can be made by contacting, by telephone or in writing: Edward Jacobs, Ph.D. at extension 10.
Edward Jacobs, Ph.D. & Associates
__________________________________________ (Name of Patient)
• I have received and read, and understand and agree to, the OFFICE
POLICIES AND CONSENT TO TREATMENT AGREEMENT of Edward Jacobs, Ph.D. & Associates, have had the opportunity to ask questions,
and agree to receive services from the practice. I consent to my protected health information being used by Edward Jacobs,
Ph.D. & Associates to provide psychological services, and to maintain health care operations. I understand that this complete
document, including the signature page, is available for my review online at www.jacobsassociates.org and at the office of Edward Jacobs, Ph.D. & Associates.
Signature and Date:_____________________________________________________________
I authorize and agree to pay for any and all services that I receive that have not been authorized or not paid for
or have been denied by my health insurance or that have been paid at a rate reduced from the usual and customary fee by my
health insurance carrier. These services might include, but are not limited to, initial appointments ($250 per 45 min.),
counseling and psychotherapy, consultations, report writing, document review and preparation, telephone calls, travel time,
missed appointments and late cancellations ($215 per 45 min.), neurofeedback ($140 per half hour), quantitative electroencephalography
($950), Wechsler Individual Achievement Test testing ($880), psychological, neuropsychological and educational testing, tutoring,
and court time and testimony (fees determined on case by case basis). The fees for these services have been discussed
with me. I AGREE TO WAIVE THE RIGHT TO BILL MY INSURANCE FOR NEUROFEEDBACK OR QEEG SERVICES AND TO PAY FOR THESE
agree to indemnify and hold harmless Edward Jacobs, Ph.D. & Associates and any of its employees or consultants for any
use made of its evaluations, testimony, consultations, reports or records by any third party.
• I authorize the release of protected health
information, both verbal and written, from Edward Jacobs, Ph.D. & Associates, to my/my child's primary care physician,
__________________________ of ___________________________________ related to my/my child's mental health and health concerns.
• I authorize the release of any medical or other information necessary to process health
• I authorize payment of medical benefits to Edward Jacobs, Ph.D. &
Associates, 12 Parmenter Road, Londonderry, NH 03053, for services rendered.
• I authorize
the release of information to the Insurance Commissioners of the States of New Hampshire and Massachusetts related to claims
for services that are billed to my insurance that are not processed accurately.
• I authorize
Edward Jacobs, Ph.D. & Associates to bill any outstanding patient balance each month to the credit card indicated below.
I authorize and agree to the above conditions: Signature and Date: _______________________