BIOFEEDBACK ENROLLMENT AND CONSENT FORM

Please review the terms of the Agreement and then complete the form below it.

Only fill out this form if you were already instructed to by our staff. If you are a new or existing client expressing initial interest in Biofeedback, fill out this form instead.

I understand Ellie Wolf, BCB, is a Board Certified Biofeedback Fellow, qualified to help me reduce my stress, manage my pain and improve the quality of my life.

I understand that if I have — or if I think I have — a medical concern, condition, disease, disorder, issue or symptoms, Ellie Wolf will help me reduce any related stress and refer me to a licensed medical professional for further assistance.

I also understand if I have — or if I think I have — a psychological or emotional concern, condition, disease, disorder, issue or symptoms, Ellie Wolf will help me reduce any related stress and refer me to a licensed professional for further assistance.

I further understand that Biofeedback is not a substitute for adequate medical care, and I intend to remain under the care of my primary healthcare provider. I understand it is my responsibility to advise Ellie Wolf of anything that might help us work together to better achieve the stress reduction I seek.

I understand that the State of New Jersey issues certifications to health and wellness professionals authorizing them to analyze, assess, evaluate, examine and investigate their patients to address any medical issue. This certification also authorizes them to advise, caution, counsel, guide, recommend and suggest interventions, remedies, and treatments to address any medical issues.

I understand that Biofeedback services are usually not covered by insurance. In the course of receiving Psychotherapy or Health Management services at IPG, my insurance may be billed and used to help pay for my treatment(s). However, I understand that I am ultimately financially responsible for my treatment at IPG if my insurance or any other third-party payer decline to pay for some or all of my treatment.

FEES

Initial evaluation and first treatment:  $200 (approx. 75-90 minutes)
Regular follow-up session 45-60 min: $150
Brief follow-up session 30 min: $100
6-session Package: $780 ($130 per session)
10-session package: $1200 for 10 sessions, ($120 per session)
Missed sessions are charged to the patient at the same rate as the fee itself (i.e. $150, $100, etc)
Scheduling Fee (for skipped sessions not cancelled with 24 hours advance notice): $50 [only for patients whose insurance is covering their visits]

SPECIFIC INSTRUCTIONS FOR BIOFEEDBACK SESSIONS

  1. The treatment room will be sanitized after every patient, including all contact surfaces, equipment and cables. You might be asked to help emplace certain sensors. But we will remove the sensors safely. Please do not remove sensors- even if they are or appear to be disposable.
  2. Seating is arranged to facilitate social distancing to the extent possible and practical, while dual Biofeedback monitors are in use.
  3. Patients and staff will be required to wear KN95 or N95 masks while in the office and during the entire session. We ask that you please arrive wearing your mask. Please let us know ahead of time if you need one and we will provide it. But it is helpful and preferable for you to please get your own. During certain times we might also require wearing a face shield. If so, we will provide a face shield, and please keep it for future use.
  4. If you have a caregiver who is assisting you, they are asked to wait in the waiting area during your appointment. If they need to join you in the treatment room, they will also need to wear a KN95 or N95 mask.
  5. Upon arrival, each patient (and parent if applicable) may be screened for temperature with a non-contact infrared thermometer and/or asked specific questions regarding common symptoms of Covid.
  6. Please use hand sanitizer before your treatment session. We have a supply in the waiting area and in the treatment offices.

GENERAL CONSENT FOR IN-PERSON TREATMENT AT IPG

I understand the following with respect to in-person treatment during the ongoing Covid-19 pandemic:

  • Covid-19 is an extremely contagious and dangerous disease spread mainly from person to person through airborne respiratory droplets.
  • The Centers for Disease Control and my state and local authorities have strongly recommended obtaining an available vaccine for Covid-19 to help minimize the risk of contagion.
  • While IPG has adopted reasonable safety precautions to minimize the risk of potential transmission of Covid-19 there is still a possibility of transmission as a result of attending in-person treatment.
  • Federal and state laws authorize public health departments to collect patient information to prevent or control disease and for related public health needs, and IPG may be required to report Covid-19 related patient information to public health departments, HHS, or the CDC if anyone who has been in my therapist’s office tests positive for Covid-19. If such reporting is required, I understand that only the minimum necessary information will be disclosed.

To minimize the risk of Covid-19 transmission, I agree to the following:

  1. I may only attend treatment in-person if I have been vaccinated and am symptom-free.
  2. I will keep my in-person appointment only if I have been fever-free for a minimum of 5 days prior to my appointment.
  3. If on the day of my temperature is elevated (100⁰ Fahrenheit or more) or if I have other symptoms of Covid-19, I agree to cancel the appointment or proceed using telehealth (if available) [Missed session fee will not apply in this case]
  4. I will cancel my appointment if I have been in contact with someone who has tested positive within the last 7 days [Missed session fee will not apply in this case]
  5. I understand that if my therapist believes I have been exposed to or may be infected with the virus, I may immediately be sent home.

This consent shall be in effect for the duration of my treatment at IPG.

Patient Information

//

Tell us about you

The more you can answer, the better prepared we will be to help you.
(as diagnosed by your therapist or psychiatrist, if applicable)
(if you know it)
(as diagnosed by your physician, if applicable)
(if you know it)
(please list all, and their dosages, if known)
On a scale of 1 to 10 (1 being very mild, and 10 being the worst pain imaginable)

Acknowledgement and Authorization

In case we need to reach out to you with any questions
For emailed copy of this form