Neurofeedback Assessment Survey
Please complete this survey to help us understand your background, symptoms, and goals for neurofeedback training.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
 -
Month
 -
Day
Year
Date
What are your main reasons for seeking neurofeedback? (Select all that apply)
*
Attention difficulties (ADD/ADHD)
Anxiety or stress
Sleep problems
Mood regulation
Headaches or migraines
Peak performance
Other
Please rate the severity of the following symptoms over the past month.
*
Rows
Not at all
Mild
Moderate
Severe
Difficulty concentrating
1
2
3
4
Restlessness or hyperactivity
5
6
7
8
Anxiety or excessive worry
9
10
11
12
Sleep disturbances
13
14
15
16
Low mood or depression
17
18
19
20
Irritability or mood swings
21
22
23
24
Headaches or migraines
25
26
27
28
How would you rate your overall sleep quality?
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
Have you previously tried any of the following treatments or therapies? (Select all that apply)
Medication
Counseling or psychotherapy
Cognitive behavioral therapy (CBT)
Other neurofeedback/brain training
None of the above
Other
Are you currently taking any medications?
*
Yes
No
Please describe any relevant medical or psychological diagnoses (if any):
How often do you engage in the following activities?
Rows
Never
Rarely
Sometimes
Often
Daily
Physical exercise
29
30
31
32
33
Mindfulness or meditation
34
35
36
37
38
Caffeine consumption
39
40
41
42
43
Alcohol use
44
45
46
47
48
What are your main goals or expectations for neurofeedback training?
*
Is there anything else you would like us to know?
Submit Assessment
Should be Empty: