Biofeedback Therapy Intake Form
Please complete this form to help us understand your health background and therapy goals before starting biofeedback sessions.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What are your main reasons for seeking biofeedback therapy? (Describe your symptoms or concerns)
*
Please list any current medical diagnoses or health conditions
*
Are you currently taking any medications? If yes, please list them.
Have you previously received any biofeedback or other therapy treatments? If yes, please specify.
Do you have any of the following conditions? (Select all that apply)
High blood pressure
Heart condition
Diabetes
Seizure disorder
Chronic pain
Anxiety or depression
None of the above
Other
What are your goals or expectations for biofeedback therapy?
Client Signature (Please sign below)
*
Submit Intake Form
Submit Intake Form
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