Informed Consent form

INFORMED CONSENT

Thank you for choosing Neurofeedback and Counseling or Columbus Counseling LLC. This document is intended to inform you of our policies, State and

Federal Laws and your rights. If you have other questions or concerns, please ask and we will try our best to give you all the information you need. 

Connie Welsh, P.C.C. has earned a Bachelor of Industrial Engineering and a Master’s Degree in Labor and Human Resources from Ohio State University. She has also received a Master’s in Counseling from Liberty University in 2009. She is licensed by the State of Ohio as a Licensed Professional Clinical Counselor. She has experience with group, individual and family therapy. She also has BCIA certification in neurofeedback.

This information is required by the counselor, social worker, and marriage and family therapist board, which regulates the practices of professional counseling, social work, and marriage and family therapy in this state.” and, immediately beneath those words, the name, address, and telephone number of the board.

50 West Broad Street, Suite 1075

Columbus, Ohio 43215-5919

Tel: (614) 466-0912 Fax: (614) 728-7790

CONFIDENTIALITY AND EMERGENCY SITUATIONS

Your verbal communication and clinical records are strictly confidential except for a) information you and/or you child or children report about physical or sexual abuse; then, by Ohio State Law, I am obligated to report this to the Department of Children and Family Services, b) where you sign a release of information to have specific information shared and c) if you provide information that informs me that you are in danger of harming yourself or others d) information necessary for case supervision or consultation e) when required by law and f) to your insurance company for payment of claims. If an emergency situation for which the client or their guardian feels immediate attention is necessary, and a call is not returned within 15 minutes, the client or guardian understands that they are to contact the emergency services in the community (911) for those services.

Currently my email and text to my office number are not HIPPA compliant. Please limit texts for communication on scheduling (ie: I am running late, I am sick and have to cancel my appointment, I need to schedule an appointment). Occasionally, you may have to email me something or I may have to email you something. Please use text and email at your own risk.

FINANCIAL/INSURANCE ISSUES

I am in network for many panels but neurofeedback is rarely covered. Please call your insurance company and make sure I am on your panel. Also if you are interested in neurofeedback, please make sure CPT code 90876 is covered. Get a confirmation code from your insurance company.

My rates are as follows: Please understand I am obligated to charge you my negotiated insurance rate which may be lower than my published rates. Call me and I will give you the rate if I know it. Note: any rate I give is subject to change from your insurance company.

Price List

Note: Please contact me to determine if you qualify for a reduced neurofeedback rate.

Assessment - $100

Counseling for 60 minutes - $100

Counseling for 45 minutes - $75

Counseling for 30 minutes - $60

Neurofeedback 45-60 minutes - $75

Neurofeedback 30 minutes (add on with counseling) - $35

NOTICE OF PRIVACY PRACTICES AND CLIENT RIGHTS

I/We have read and received a copy of the Notice of Privacy Practices and Client Rights document. Please note this is on my website nacoc.net under Privacy Practices.
 

CONSENT FOR TREATMENT OF CHILDREN OR ADOLESCENTS

I/We consent that _____________________________________ maybe treated as a client by Connie Welsh.