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Hogan Pesaniello, M.D.
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INFORMED CONSENT
Kimberly Hogan Pesaniello, MD 6455 Maddox Blvd, Suite 4 Chincoteague Island, VA 23336 (757) 336-6544 Informed Consent for Neurofeedback Training I hereby authorize K. Hogan Pesaniello, MD to provide me with neurofeedback training. I understand that this training is used for a variety of conditions which appear to be associated with irregular brain
activity, including but not limited to ADHD, depression, anxiety, stroke and seizure disorders. Training is recommended on
the basis of empirical observation of improvement in clients with similar conditions. I understand that EEG biofeedback requires placement of surface electrodes on my scalp for the purpose of recording my
EEG, and the use of this signal to provide video displays and audio signals to reinforce my brain behavior. I understand that some individuals have reported that training may affect my body’s response to medications for my
condition and for unrelated conditions. I understand that I should not stop or alter any of my medications without consulting
my physician and psychiatrist. I should continue ongoing therapies until otherwise advised by Dr. Pesaniello and my other
physicians. Should any new symptoms develop, it is my responsibility to inform my health care providers including my neurofeedback
practitioner. I understand that it is the client’s own responsibility to monitor the subjective effects of training. Neurofeedback
is based on the input of the client’s report from day to day sessions as well as from the initial evaluation and depends
on the full participation of the client i.e. his /her feedback about the effects of the training. The research literature
indicates that there are some individuals who are apparently unaffected by training. Accordingly, the client is encouraged
to evaluate progress after about ten sessions to determine if further training is indicated. Discussion is invited at this
point or any time during the training. I acknowledge that Dr. Pesaniello has reviewed with me the procedure of neurofeedback, the reason for the recommendation
to engage in neurofeedback, the risks involved, and alternative treatments. I understand there is risk of negative effects,
including worsening of my condition for which the training is being performed. The training is noninvasive and appears to
be a harmless procedure as far as is known at present. No injuries are known or reported in the literature. No representation is made that any individual client will improve from training. There is some indication that some client’s improvement may fall off after the cessation of training. These individuals
would benefit from periodic follow up or booster sessions. Date______________ Signature_________________________________ Printed Name_____________________________ Signature of person explaining the form _____________________________________________ ***************************************************** Kimberly Hogan Pesaniello, MD 6455 Maddox Blvd, Suite 4 Chincoteague, VA 23336 (757) 336-6544 Authorization for Disclosure of Protected Health Information To:_______________________________________ Re:_____________________________________ Person, agent or facility receiving information Patient’s full name Address:_____________________________________________________________________________ DOB:_____________________________________ SSN:_____________________________________ ___I hereby authorize Hogan Pesaniello, MD to disclose TO the above person, agency, or facility the following information: ___I hereby authorize the above person, agency or facility to disclose TO Hogan Pesaniello, MD the following information: __Initial Evaluation __Treatment Plan __Diagnosis __Treatment Summary __Progress notes from (date___) __Medication History __Psychiatric History __Substance abuse evaluation __Personal History __Discharge Summary __Results of laboratory tests (HIV results included):___________________________________ __Results of alcohol or other drug testing_____________________________________________ __Alcohol or drug abuse treatment (be specific)______________________________________ __Other (be specific):__________________________________ Disclosure: __To assist in diagnosis, consultation, and/or treatment __Other (be specific):________________________________________________ ______________________________________________________________________ I understand that my records are protected under Federal regulations governing Confidentiality of Alcohol and Drug Abuse
Patient Records, the Health Insurance Portability and Accountability Act of 1996, and/or Virginia statutes on the confidentiality
of medical, mental health, and mental retardation information. I understand that my records cannot be disclosed without my
written consent unless the law otherwise permits such disclosure. I understand that in some situations I may be able to inspect
or copy the information to be used or disclosed under this authorization. I understand that any disclosure of information
carries with it the potential for an unauthorized re-disclosure and the information may no longer be protected by federal
or state confidentiality rules. A general authorization for the disclosure of medical or other information is not sufficient
for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol
or drug abuse patient. A copy of this may be accepted in lieu of the original. This authorization will expire ______________unless
revoked by me (in writing) prior to date, event, or condition. This authorization ___includes ___does not include information placed in my records after today’s date I acknowledge further that the information to be disclosed was fully explained to me, and this authorization is given of
my own free will ___________________________________________________ DATE________________ Signature of Client ___________________________________________________ Signature of legally authorized representative ________________________________________________ Signature of person explaining form |
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