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.) ◊ Independent Clinical Social Worker (Vicki Jacobs, MSW), governed by the Code of Ethics of the
American Psychological Association (Edward Jacobs, Ph.D.) ◊ National Association of Social Workers (Vicki Jacobs, MSW).
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,V. Jacobs). 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 and quantitative EEG arepart of the practice of Edward Jacobs, Ph.D.
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 to you.
Communication 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.
There are 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:
you give me permission to bill a third party for my services, and I agree, 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 times.
In an emergency, call 911 or go to your nearest emergency room and then try to 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.
I 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.
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 will be.
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.
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
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
Maintenance of Records:
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:
I 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.
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.
Treatment 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.
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
Billing and Insurance Coverage
My billing rate is $250 for initial appointments, $250 per 45 minute session, and $250 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 $150 per half-hour training session. Academic assessments range from $1200 - $2000. Psychological and neuropsychological
assessments range from $3000 - $4500. The fee for a quantitative EEG is $950. Academic assessments range from $1200
- $2000. Psychological and neuropsychological assessments range from $3000 - $45000. 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.
As a 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.
You are 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 ($250 per 45 min.), neurofeedback ($150 per half hour), quantitative electroencephalography
($950), Wechsler Individual Achievement Test testing ($1200), psychological, neuropsychological and educational assesments
(fees range from $3000 - $4500), 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 SERVICES DIRECTLY.
• I 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
RELEASE OF INFORMATION
• 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 insurance claims.
• 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: _______________________