Neurofeedback New Client Forms 

Welcome!

It was a pleasure speaking with you and on behalf of our office I would like to congratulate you on taking the next step toward improved health and wellness!  We believe you are in the right place and have seen many clients obtain fantastic results!

Please fill out the following information that our office requires you to complete and hand back to us at least 1 week prior to your first visit. We would greatly appreciate it if you would complete and return all forms as soon as possible, as our team requires time to review and prepare for your first visit.

 

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Address
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Tell us more about your needs and desires regarding brain health.

HEALTH INFORMATION

1. OVERALL HEALTH

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2. SLEEP

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3. HEAD OR NECK INJURY

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4. CHRONIC HEALTH PROBLEMS?

5. HORMONES

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6. MOODS & EMOTIONS

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7. MEDICATIONS, SUPPLEMENTS & VITAMINS

8. SUBSTANCES

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9. ATTENTION & LEARNING

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10. OTHER CONDITIONS

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11. COUNSELING & PSYCHOTHERAPY

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12. SEIZURES OR LIGHT SENSITIVITY?

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13. Is there anything that you would like to add?

Parent or Guardian of Minor, please complete this section