We hope you are as excited as we are to get started on your journey to Brain Harmony.
Important Contact Information
Brain Harmony has a team approach to care. If at any time you are wondering what is next or you have any concerns, please do not hesitate to call Ellen at 727-999-9124 ext. 101 or email email@example.com.
Faster Stronger Smarter
We know we can improve brain organization and function in people of all ages because the brain grows, changes and creates new pathways in response to stimulation and input from the environment. We create change with frequency, duration and intensity of therapeutic input. The more therapy you complete, the faster, stronger and smarter you or your family member will become.
From Our Family to Yours,
Carol Garner-Houston, OTR/L
Co-Founder and Chief Clinical Officer, Brain Harmony
Nationally Licensed Occupational Therapist
Lara Garner Shane
Co-Founder & Chief Executive Officer
Permission to Administer Therapy
Please complete this form. By completing this form, you are giving your consent for treatment.
This approval includes my consent for treatment and my consent for Brain Harmony staff to share and receive information for the purpose of helping my child succeed.
I authorize this sharing of information with the following guidelines or exceptions: The patient authorizes Brain Harmony to advise, as he/she deems appropriate, through the use of iLs, and the patient gives the authorization for these protocols to be used. The patient has the right to informed participation in decisions involving his/her health care. This shall be based on clear, concise explanation of his/her condition and of all proposed treatment procedures. All possible risks and/or side effects as well as the probability of success with such procedures shall be disclosed to the patient. Bipolar and seizure disorders may be contraindicated when using iLs. Implantable devices, such as pacemakers and defibulators, and pregnancy are contraindicated for alpha stim. I understand that it is my responsibility to disclose any possibility of bipolar, seizure disorders, implantable devices and pregnancy to Brain Harmony for the safety of my child.
The patient will not hold the Brain Harmony responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. The patient shall not be subjected to any procedure without his/her voluntary, competent, and understanding consent or the consent of his legally authorized representative. Where medically significant alternatives for care or treatment exist, the patient shall be so informed. After reading the above (or having it read to me), I hereby consent for my child to consultative services from Brain Harmony via iLs to begin on this date and terminating when determined by myself or my physician.
Identifying and Family information:
Parent information (if the patient is under 18 years of age, please fill out section below.)
Authorization for Information Exchange
I hereby authorize Therapeutic Connections, LLC. DBA Brain Harmony to give and/or receive in verbal, written, or video form information pertaining to the above-named patient.
I authorize exchange of information between Therapeutic Connections, LLC. DBA Brain Harmony and the party or parties listed below:
A photocopy of this document shall be considered to be as valid as the original. This authorization for release of information shall remain in effect until revoked and may be revoked by myself at any time by giving written notice to Therapeutic Connections, LLC. DBA Brain Harmony.
I understand that Brain Harmony may take pictures or videos of the patient to document developmental status and or clinical progress. These images and likeness of the patient will not be used without my written permission to do so.
I understand that the information obtained will be treated in a confidential manner and will not be given to a third party without my permission unless required by law.
NOTICE OF PRIVACY & HIPAA PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL & PERSONAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, WHO HAS ACCESS TO YOUR INFORMATION AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
WHO WILL FOLLOW THIS NOTICE
This notice describes our institution’s practices and that of:
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
To provide, coordinate or manage your health care and related services by both us and other health care providers (doctors, nurses, hospitals, healthcare providers, and other healthcare facilities who become involved in your care)
We may refer you to another health care provider and as part of the referral, share medical information about you to that provider.
So we can be paid for services provided to you, which can include billing you, your insurance company or a third party payer.
How we will contact you:
Unless you tell us otherwise in writing, we may contact you by either telephone, text, email or by mail at either your home or your workplace. At either location we may leave messages for you on voicemail.
Treatment Alternatives, Health Related Benefits and Services:
Your protected health information may be used to provide you with information about other healthrelated benefits or services that may be of interest to you and/or information regarding treatment alternatives.
Your signature below confirms that you agree to the information on each page of this entire packet. Signing below also confirms that all of the information that you have provided is true to the best of your knowledge. In addition, your signature authorizes the patient’s insurance benefits be paid directly to Therapeutic Connections, LLC. DBA Brain Harmony.
I understand that I am financially responsible for any balance. I also authorize Therapeutic Connections, LLC. DBA Brain Harmony to release any information required to process my claims. Please accept my digital name below as signature authority.
Developmental History for Children and Young Adults
Please take your time when completing the following developmental history. Assessment of developmental history starts from pre-conception. This allows for identification of patterns and severity of symptoms when assessing your child. This information is intended to provide the most comprehensive care possible. This information will not be released without your written consent.
Perinatal and Birth History
Perinatal and Birth History (cont.)
Adoption - If your child is adopted, please complete.
Describe the circumstances surrounding the adoption.
Medical History (cont.)