Informed Consent for Heartbreath Biofeedback Services The following checklist outlines the considerations for informed consent. 1. Voluntarily Participation. Clients voluntarily agree to treatment and can terminate at any time without penalty. Participation in the HeartBreath Biofeedback service is offered as one option of intervention in a stated presenting problem upon intake through the counseling and consulting practice of Gleaves Consulting. Biofeedback services may be offered at the time of assessment to address specific problems of anxiety and/or depression, however are optional. The client can discontinue biofeedback services at any time and will not have a penalty. Choosing to opt out of biofeedback services does not prevent a client from continuing with clinical services offered through Gleaves Consulting. It is further understood that participation in the Heartbreath Biofeedback Services is not intended for any type of evaluations to substantiate or confirm the status of family medical leave, fitness for duty, progressive disciplinary action, short-term medical disability, or return to work recommendations. Participation in the Heartbreath Biofeedback service is not appropriate for any type of evaluation in a mandatory capacity. Participation in the Heartbreath Biofeedback Service is one part of a mental health diagnostic process but is not in and of itself a diagnostic tool. 2. Client Involvement. What level of involvement and what type of involvement will be expected from clients? The client may need to provide the results from a recent physical exam to support the need for medically necessary services. Home Practice a). The client will complete a Stress Assessment Inventory and submit this at the second session. b). A central concept in the area of biofeedback is the need to breath diaphragmatically. This type of deep, even breathing will assist greatly in obtaining and sustaining a high level of coherence. Practicing diaphragmatic breathing can be a home practice activity so as to improve performance with this technique. With practice, this type of breathing pattern can be used throughout the day for brief periods of time. The nature of this technique requires that the client practice various home assignments between sessions so as to be able to demonstrate a consistent, gradual improvement in obtaining a condition that biofeedback terms coherence. Coherence is defined as a state of synchronization between our heart, brain and autonomic nervous system, which has been proven to have numerous mental, emotional and physical benefits. Coherence is not just relaxation. Coherence is a state of relaxation and revitalization at the same time. The coherence state is achieved and sustained by activating a positive feeling and shifting back to that positive attitude and emotion. The therapeutic goal would be to learn how to achieve coherence and to be able to demonstrate an accumulated score of 200 points per day or 1500 points per week.
Clients can accomplish this goal by practicing the Quick Coherence Technique, which is defined as Heart Focus- Focus your attention on the area around your heart, the area in the center of your chest. Heart Breathing- Breathe deeply but normally and feel as if your breath is coming in and out through your heart area. Heart Feeling- As you maintain your heart focus and heart breathing, activate a positive feeling like appreciation for the good things in your life, or the love and care you feel for someone (child, spouse, pet) or something (a beautiful sunset, a fun vacation, a hobby). c). General research in the field of biofeedback commonly recommends that home practice occur at least twice a day for 15-20 minutes twice a day between sessions. The client will be given a handout to complete of their efforts. This handout will be given to the counselor for review and feedback. The handout is from the book Full Catastrophe Living by Jon Kabbit- Zinn. 3. Counselor Involvement. What will the counselor provide? The counselor will provide an individual psychosocial intake, administer standardized psychometric instruments with interpretation. To receive Heart Breath Biofeedback services the client will complete the Nijmegen Questionnaire. Medical records may need to be submitted for a stated medical condition for which biofeedback services are sought, or a the client may be asked to have a current medical/physical exam completed for rendering a medical diagnosis for stated symptoms of a medical condition. On a case by case basis, the primary counselor may participate in the biofeedback session to reinforce clinical goals and assist in the overall interpretation of data. How will this be provided? The initial intake procedures and the intake questionnaire will be completed with the counselor, the standardized psychometric testing will be completed by the client and scored by the counselor. How can the counselor be reached in the event of an emergency? As with all other clinical services provided through Gleaves Consulting, emergency or after hour calls individuals should call 911 or go to the nearest hospital emergency room. Messages for Nancy Gleaves, HeartBreath biofeedback practitioner can be left on the confidential answering machine for Gleaves Consulting at 708.422.2885. Gleaves Consulting does not utilize an on-call answering service. 4. No Guarantees. Counselors cannot guarantee results (i.e. become happier, less tense or depressed, save a marriage, stop drug use, obtain a good job, etc.) Before the advent of psycho physiological instrumentation, clinicians were entirely dependent upon their intuition and the patient s subjective reports for monitoring the interaction between mind and body. Now it is becoming
possible to assess those states more objectively and to make more accurate inferences concerning the relationship between subjective imagery, fantasies, visualization, and their neuropsychological aspects. Awareness of subtle imagery and sensations is not a prerequisite to autonomic control, although such recognition does speed up the process (Pellitier, 1977). Biofeedback training allows one to see they have the ability to modify internal states, however enduring changes comes from the integration of lifestyle change, habits, decisions to eliminate stressors in one s life and the attendant cognitive and behavior changes that go along with those changes. 5. Risks Associated with Heartbreath Biofeedback Services. Define what, if any, risks are associated with the counselor s particular approach to counseling. The most important point to make in this regard is that biofeedback is not a substitute for medical treatment or structured clinical psychotherapy. While receiving biofeedback services, the client is encouraged to continue to take medications as prescribed by his/her treating physician and to comply with recommendations made by the primary care physician. Care can be coordinated with the physician, and as clinically appropriate, relevant information will be shared with the physician. In learning to modify one s level of breathing from the thoracic or upper chest area to diaphragmatic breathing there may be dizziness or light-headedness. The therapist will ask the client if this is a symptom. If this is a symptom, the biofeedback session will stop, and the client and the therapist will process this issue. Adjustments can be made to the breath pacer so that the pacer moves at an optimal rate with the client. In some instances, but not all instances, clients may experience slower reaction times due to an overall reduction of stimulation. Clients need to be aware of possible slowed reaction times and may need to allow extra time after the session and before leaving the office. 6. Confidentiality and Privilege. Specify how confidentiality will be handled in couple counseling, family counseling, child/adolescent counseling, and group counseling situations. How may confidential and privileged information be released? Information cannot be released without the knowledge and written permission of the client. In order to release information, the client would complete specific consent forms. The goal is to promote communication between couples and family members. One partner may have a need to speak with the therapist privately, however the goal would be for this information to communicate to the other party. In the case of family therapy, again communication is the goal between the members. One if not both parents (in an intact family) are involved in family therapy sessions so as to promote open communication. Any variations of this will be decided based on the clinical needs of the case and determined by the therapist. There is no information that is stored electronically. 7. Exceptions to Confidentiality and Privilege. Confidentiality and privilege cannot be maintained in the following circumstances: Information you share is protected against disclosure by Federal Confidentiality Laws, except in
the following conditions: 1) the practitioner becomes aware of threats of suicide or homicide 2) the provider suspects a child or vulnerable person has been abused or neglected, 3) if your records are subpoenaed for court. No information can be released without your knowledge and permission. 8. Counseling Approach or Theory. What is the counselor s counseling orientation or theoretical belief system? How will that affect treatment? The orientation used during the biofeedback services originates from the field of a mind/body approach and biofeedback as a therapeutic practice is within the field of psycho physiological applications. A general definition of biofeedback is a training technique in which people are taught to improve their health and performance by using signals from their own bodies. Biofeedback is typically used as an adjunct technique to other types of therapeutic methods. A client will typically be introduced to the technique of biofeedback and some other type of clinical intervention method. Relaxation therapies to be used would be progressive relaxation, autogenic therapy, and Benson s relaxation response. Hypnotic relaxation, Transcendental Meditation, yogic meditation including deep breathing are also acceptable relaxation therapies, however are not offered through HeartBreath services through Gleaves Consulting. Techniques of biofeedback therefore are considered to be more a part of the world of complimentary medicine and are considered to be unconventional treatments that are used along with conventional medicine. The holistic philosophy of complementary medicine allows one to draw from the best of both health care worlds. The category of alternative medicine refers to unconventional treatments that are used instead of conventional medicine. Integrative medicine refers to the combination of conventional medicine with complementary treatments for which there is scientific evidence of safety and effectiveness. Integrative medicine is considered the gold standard in complimentary and alternative medicine. An important point to make is that biofeedback is a learning process in the techniques of stress reduction. Due to the nature of receiving certain types of auditory, visual, and physiological feedback, during a biofeedback session one may become overly preoccupied with the notion of perfection. This will be an obstacle for improvement. The client and the practitioner will need to work together to achieve positive results. The practitioner will need to elicit information from the client at times; the client will need to cooperate with the program, even though there may be challenges. 9. Counseling and Financial Records. What will they include? Records of the biofeedback services will include information as to date of the session; duration of the session and the amount of time an individual was able to sustain coherence. Additional observations will be made by the practitioner in terms of overall response to intervention. How long will they be maintained? Records are kept for a period of seven years.
How will they be destroyed? Paper files will be shredded. Biofeedback services that are kept digitally will be deleted. 10. Ethical Guidelines. What standard defines the counselor s practice? How might a client obtain a copy of these guidelines? The practitioner adheres to the standards and practice set forth by the American Counseling Association. The practitioner adheres to the standards and practices set for by the Illinois Association of Alcohol and Drug Professionals. The practitioner adheres to the standards and practices set forth by NAADAC. The practitioner adheres to the standards and practices set forth by the Biofeedback Certification Institute of America. Copies of these standards are available upon request. 11. Licensing Regulations. What license does the counselor hold? The practitioner obtained a master s degree in 1984, has maintained certification at the state and national level as an addictions counselor since 1987, and has been a Licensed Clinical Professional Counselor since 1995. How may a client check on the status of the licensee? The official status of a professional license and any applied disciplinary actions can be verified at www.idfpr.com 12. Credentials. What education, training, and experience credentials will the counselor need to provide counseling treatment, including any specialty credentials. The practitioner obtained a master s degree in 1984, has maintained certification at the state and national level as an addictions counselor since 1987 and has been a Licensed Clinical Professional Counselor since 1995. The practitioner has 30 years experience providing behavioral health services in the areas of domestic violence, substance abuse, and child welfare. 13. Fees and Charges. Heartbreath Biofeedback Services are specialty services through the counseling and consulting practice of Gleaves Consulting. Due to the nature of the services, sessions will only be 45 minutes long, and a fee of $75.00 will be charged. A no show fee of $35.00 will be charged if less than 24 hours are given for cancellation. Giving notice for cancellation is a standard courtesy in the medical profession. If biofeedback services are a covered benefit in an individual s plan, authorization will be established and a quote of benefits obtained by the practitioner. Some plans may not cover biofeedback services. There are no reports issued for biofeedback services.
How will fees be collected? Deductibles may be applicable to certain plans. A particular benefit plan is not activated until deductibles are paid. Copayments, coinsurance amounts are due at the time that a session is rendered. How are financial records maintained? Paper claims are filed. At the time of intake, an insurance form will be signed on behalf of the client. Clients are ultimately financially responsible for the payment of services rendered. Receipts will be issued with a scheduled appointment time. 14. Insurance Reimbursement. What responsibility will the counselor take for filing insurance forms? What fees, if any are associated with insurance filing? How will co-payments be handled? At the time of the initial request for service, information is collected regarding an individual s benefit plan and the provider calls the insurance company for a quote of eligibility and benefits. Insurance forms are completed by the practitioner and submitted for payment. 15. Responsibility for Payment. Who is responsible for payment of counseling charges? How will delinquent accounts be handled, what charges will be assessed for delinquent accounts? The stated member will be responsible for counseling charges. Invoices will be given for delinquent accounts. A client will be referred out if an outstanding balance is on the account and has not made arrangements with the practitioner. Delinquent accounts may be referred to a collections agency. 16. Disputes and Complaints. The strong preference of the practitioner is that the client discuss the issue at hand and together the practitioner and the client come to a resolution. Clients have the choice to register complaints with their insurance vendor. 17. Cancellation Policy. How much notice for cancellation of a scheduled appointment is required? What fees will be charged for late cancellations? A no show fee of $35.00 will be charged if less than 24 hours are given for cancellation; this is a standard courtesy in the medical profession. 18. Affiliation Relationship. Describe independent contractor and/or partnership relationship with other practitioners. The only practitioners who are involved in the consulting practice of Gleaves Consulting are Dr. Kenneth Gleaves and Nancy Gleaves.
19. Supervisory Relationship. Describe any required supervisory relationship along with reason for the supervision. Provide supervisor s name and credentials. Depending on the needs of the case, consultation and collaboration will be provided by Dr. Kenneth Gleaves 20. Colleague Consultation. Consultation is an effort to provide continuous quality improvement with the clinical needs presented. Consultation is a generally accepted standard of care. Given the nature of biofeedback services, specifically that certain physiological information is collected, consultation and collaboration will be obtained by Dr. Kenneth Gleaves.
Rev.12/2014 CHECKLIST FOR INFORMED CONSENT FOR HEARTBREATH BIOFEEDBACK SERVICES The client understands he/she may need to provide the results from a recent physical prior to participating in the Heartbreath Biofeedback Service. The client verbally communicates understanding that they will need to accept responsibility for their involvement in biofeedback home practice activities. The client understands that he/she voluntarily agrees to treatment and can terminate at any time without penalty. The client understands that no reports will be issued to substantiate or confirm family medical leave, fitness for duty, progressive disciplinary action, short term medical disability or return to work recommendation. The client understands that participation in the Heartbreath Biofeedback Service is one part of a mental health diagnostic process but is not in and of itself a diagnostic tool. The client verbally communicates understanding the specific activities the counselor will provide during the course of biofeedback services and procedures for emergency or after hours messages. The client verbalizes understanding that participation of clinical counseling services or biofeedback service does not guarantee positive results or outcomes.
Client verbalizes understanding of the risks associated with biofeedback services The client verbalizes understanding of confidentiality both in a clinical setting and also in biofeedback services. The client verbalizes understanding of the exceptions to confidentiality and privileged communication. The client verbalizes an understanding of the fees and charges related to biofeedback services. Client verbalizes understanding of the process of insurance reimbursement as described above. The client verbalizes an understanding of financial responsibility for services rendered. Client verbalizes an understanding of the complaint process with their insurance vendor. Client verbalizes an understanding of the cancellation policy and that a fee of $35.00 will apply to no shows and cancellations. Rev.12/2014