Neural Feedback Session Intake Form

Neural Feedback Session Intake Form
Please complete this form to help us prepare for your neural feedback session. All information is confidential.
Full Name*
First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*
MonthDayYear
Date
Preferred Appointment Date and Time*
What is your primary reason for seeking neural feedback?*
Epilepsy or seizure disorderHistory of traumatic brain injurySleep disordersAnxiety or depressionNone of the aboveOther
Are you currently taking any medications? If yes, please list them.
YesNo
Emergency Contact Name and Relationship*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Signature (Please sign to confirm your information and consent)*
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