Neurofeedback Therapy Application Form

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Gender *

Male
Female

Age *

How would you describe yourself? *

If we call you, may we leave a message with someone else?

Yes
No

I'm particularly interested in (tick all that apply): *

HOW DID YOU HEAR ABOUT US? *

Handedness *

Right
Left
Ambidextrous

Have you had any suicide attempts/Plan or attempts of self-harm? *

Yes
No

Do you use alcohol? *

Never
Daily
Occasionally/socially

Have you had any hospitalizations related to psychiatric or mental heal issue? *

Yes
No

If yes, explain:

Do you have any psychiatric or mental health diagnoses?

Yes
No

If yes, explain:

Do you have a history of using recreational drugs? *

Yes
No

If yes, explain:

Goals for training or primary problem(s) you'd like to improve *

List all prescribed medications/how long on them?/comments *

List all supplements/OTC medications/how long on them?/comments *

Check any of these which apply:

Poor self-esteem
Excessively obsessive or worried
Excessively obsessive or worried

History of help utilized *

Provide any important family history issues that may relate to current challenges/symptoms (divorce, disruptions in family, major job challenges, loss of family or friend, etc.)

File Upload

Click or drag a file to this area to upload.

Comment or Message *

How did you find us? *

Neurofeedback Therapy Application Form

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