Neurotherapy Session Sign-off
Please complete this form to document your neurotherapy session and acknowledge participation.
Participant Full Name
*
First Name
Last Name
Participant Email Address
*
example@example.com
Participant Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Session Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Type of Neurotherapy Session
*
Please Select
Neurofeedback
Biofeedback
Cognitive Training
Other
Reason for Session / Presenting Issue
*
Practitioner Full Name
*
First Name
Last Name
Pre-Session Checklist (select all that apply)
No caffeine consumed within 4 hours
Adequate sleep last night
No seizure in the past 24 hours
Medications taken as prescribed
Other
Emergency Contact Name and Phone Number
*
Please rate your comfort level before the session
Not comfortable
1
2
3
4
Very comfortable
5
1 is Not comfortable, 5 is Very comfortable
Participant Comments or Feedback (optional)
Participant Signature
*
Submit Sign-off
Submit Sign-off
Should be Empty: