New Client Form | Dr. Hutton Neurofeedback

Personal Information

Basic Contact Information*

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Date of Birth*

Are you at least 18 yrs of age?*

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Address*

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Phone (Primary)*

Phone (Secondary)

Occupation*

Emergency Contact

Name*

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Phone*

Relationship to Client*

Parent or Guardian of Minor

Name*

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Address*

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Phone (Primary)*

Phone (Secondary)

Reason for Visit

Primary Symptoms or Diagnosis

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Referring Physician*

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Specialty*

City / State*

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AGREEMENT TO PAY FOR PROFESSIONAL SERVICES

APPOINTMENT SCHEDULING:

We ask your cooperation in maintaining a schedule and keeping appointments. If you want a regular appointment time, we will schedule your sessions for the same days and times each week. New appointments can also be scheduled after each session.

APPOINTMENT CANCELLATION POLICY:

We ask that you please provide at least 24 hour notice if you need to cancel an appointment. Other clients might be able to fill a cancelled appointment time. You may be charged the full session fee if we do not receive 24 hour notice of cancellation. We recognize that there are times when emergencies arise, and we ask your cooperation in notifying us as soon as possible when your plans change.

PAYMENT AGREEMENT:

Although other persons may make payments on your account, you are responsible for the services provided by Hutton Neurofeedback staff at the time of service.

REFUND POLICY:

We offer a discounted fee with prepayment for 20 sessions. If you decide to terminate neurofeedback training before completing 20 sessions, already completed sessions will be billed at the usual non-discounted per-session fee. Any remaining balance will then be refunded to you.

REQUEST:

We serve many chemically sensitive clients, so we ask that you refrain from using fragrances when coming to this office. Your cooperation is greatly appreciated.

Signature*

Printed Name*

Date*

CONFIDENTIALITY / MANDATED REPORTER STATEMENT

Hutton Neurofeedback, in offering EEG biofeedback, as well as sport consulting services, understands the confidential nature of client information. Although information shared during the course of treatment is designed to be confidential, it is important to understand the limits and definitions of confidential material.

Information shared with Hutton Neurofeedback staff become part of the treatment file. Review of pertinent treatment material occurs on a regular basis with the treatment team.

Although treatment is designed to be confidential, some staff members are licensed clinicians and health providers, who by the nature of their license have specific criteria for when confidentiality can and must be breached. While confidential information can normally be released by Hutton Neurofeedback only when there is a written release from the client, there are the following exceptions:

Personnel are mandated reporters for a reasonable suspicion of child, dependentor elder abuse. If such a suspicion arises, they are mandated to report it to the authorities.
Confidentiality can and must be breached when clients present a danger to themselves or others (suicidal or homicidal ideation). While it is their legal responsibility to report, it is also their ethical responsibility to help negotiate such a crisis.
Intent to destroy property may also be cause for breaching confidentiality. When treatment records are under a court subpoena, records and confidential communications can also be breached.

Informed Consent

Dr. Chea Hutton-Chitwood offers EEG (brain wave) biofeedback training to clients in connection with a variety of conditions that appear to be associated with disregulation of brain activity, including hyperactivity and attention deficits, behavior problems, sleep disorders, depression, anxiety, chronic pain, brain injury, seizures, and other conditions. EEG biofeedback training is also provided for clients who wish to enhance brain regulation for improved performance.

Dr. Hutton is not a physician. She has been trained and certified through the EEG institute. She is aware, by experience and through the literature, of beneficial effects of the kind of biofeedback she offers, including remediation of attention deficits and hyperactivity, recovery from some of the consequences of brain injury, and the reduction of incidence and severity of seizures. Scientific investigation is ongoing to determine the mechanism by which these benefits are achieved. At present, Dr. Hutton agrees with the EEG Institute who recommends the training on the basis of empirical observations of improvement in clients with similar conditions.

No guarantee is made that any individual client will improve with training. It is possible that for a few clients who do experience benefit, the improvement may fall off after the cessation of training. Those individuals would benefit from periodic follow-up or booster sessions. The training appears to be a harmless procedure as far as is known at present. No injuries are known in the experience of EEG Institute, or in the literature reviewed.

Neurofeedback is a non-invasive procedure. Nevertheless, beyond this Dr. Hutton a does not make any representation concerning the safety or efficacy of training. Any questions should be addressed to the prospective client’s physician. The client should continue ongoing therapies until otherwise advised by a physician. It is the client’s responsibility to monitor the subjective effects of training and to continue training so long as benefit is perceived. The research literature indicates that there are some individuals who are apparently unaffected by the training. Accordingly, Dr. Hutton encourages the client to evaluate progress after about ten sessions to determine if further training is indicated. Dr. Hutton invites discussion at this point or at any point in the training.

By signing this form, the client indicates his/her understanding of the principles set forth here, and waives any claim of damages due to the training, including worsening of the client’s condition for which the training was undertaken, claimed side effects, or the failure to improve with training. In addition, the client agrees to take full responsibility for his/her training, the benefit of such training, or the lack thereof, and further agrees to hold EEG Institute and Hutton Neurofeedback harmless from all claims associated with such training.

If there is a need to speak directly with your primary care practitioner, or if we need further information (reports, tests, etc.), we will request that you sign a release of information allowing us to have that communication.

The client agrees to submit any dispute with Dr. Chea Hutton-Chitwood to binding arbitration under the rules of the American Arbitration Association.

Signature*

Printed Name*

First Last

Date*