Though Mrs. Keane is a Licensed Mental Health Professional, her biofeedback services are considered an adjunct service. Mrs.Keane is unable to provide general mental-health related services outside of biofeedback. Which means I am strongly encouraged to have an ongoing mental health provider or therapist along with the biofeedback sessions. If I do not have an ongoing therapist and can benefit from one, Mrs. Keane may recommend me to ongoing therapy services and can assists with referrals. The referral process often requires Mrs. Keane sharing the reason for referral and at times to seek consultation with a mental health professional or biofeedback provider regarding your care. Mrs. Keane will not share identifiable information about me in this case.

You must give signed permission before Mrs. Keane can share any facet of your sensitive information with anyone outside of those discussed above. If you give Mrs. Keane written permission, you will have the right to designate who additionally should receive general information about this adjunct service such as an ongoing therapist, psychiatrist, or physician.

Payment Policy: Payment is due at the beginning of each session. Mrs. Keane’s fee is $100.00/hour for SoundSelf Biofeedback, and must be paid by the client at the onset of each session. On a case by case basis, Mrs. Keane may strongly decline to provide biofeedback and recommend a follow up appointment and connection with an ongoing mental health provider or physician if needed to provide stabilization due to imminent risks or concerns I am presenting with in my initial appointment prior to being permitted to receive biofeedback. At this time if it is determined best to have a counseling support session I will be given the option to sign a consent to release information to be referred out to an additional support therapist who can provide counseling treatment.

Mrs. Keane is considered a private pay provider. I will be responsible for covering the full cost of session at the time of the initial appointment and signing a release to not utilize my insurance for the assessment. Mrs. Keane will not work with my insurance company for reimbursement for SoundSelf and biofeedback and it is my responsibility to try and recoup any costs from my insurance company independently if I wish to do so. If a form of payment, personal information, and consents are not provided at the time of the assessment session, I will have to reschedule my meeting to after they are completed. Further, if you make statements that indicate you intend to harm yourself or others, Mrs. Keane is mandated to contact the appropriate crisis support and/or emergency contacts provided.

Phone Consultation: After the first fifteen (15) minutes of phone consultation, clients are billed $20.00 per ten (10) minutes.

After the first ten (10) minutes, clients are billed a minimum of $20.00. Immediate after calls payment is required.

Please see the examples below:

Example A: Thirty (30) minute phone consultation First fifteen (15) minutes = free of charge Twenty (20) minutes of phone consultation = $40.00

Example B: Forty-five (45) minute phone consultation First fifteen (15) minutes= free of charge Thirty-five (35) minutes of phone consultation = $70.00

Subpoenas and Court Costs: Mrs. Keane’s retainer for attending court (with or without a subpoena) is $2000.00. Subsequent fees are $400 an hour (including travel time) plus any other expenses incurred (i.e., gas, airfare, car rental, hotel etc).

Cancellation Policy: Cancellation of an existing appointment must be made at least twenty-four (24) hours in advance. If the initial appointment is canceled less than 24 hours before the scheduled time, the participant will be billed $100.00 (for the missed meeting) for an initial meeting a receipt will be provided to the participant and the card on file will be charged for the cancellation fee at the time of the missed appointment.

Furthermore, if Ms. Keane is not contacted to reschedule or cancel an appointment (at any time), she will make one attempts to contact the participant. Subsequently, a $100.00 invoice (for the missed appointment) will be mailed to the participant. The participant will be responsible for the full amount. Unforeseen or emergency situations will be taken under consideration. I am required to communicate with Mrs. Keane the reason for cancellation prior to missing my appointment unless I am unable to gain access to a phone.

By engaging in the biofeedback process, I understand and commit to the activities and policies outlined in this document. By signing below, I affirm that I have read and discussed the information herein with Mrs. Keane. I understand the risks and benefits of biofeedback, the nature and limits of confidentiality, and my responsibility as a participant.

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Participant Signature Date