Consent to Biofeedback/Neurofeedback Treatment


VOLUNTARY NATURE OF BIOFEEDBACK/NEUROFEEDBACK TREATMENT

 

I voluntarily consent to biofeedback/neurofeedback treatment at InMindOut Emotional Wellness Center, LLC.  I have been provided information:

  • Treatment purposes
  • Methods and effects
  • Preparing for the first session
  • Potential side effects
  • Payment information

 

I was given the opportunity to ask questions about biofeedback/neurofeedback, and any questions I asked were answered to my satisfaction.

 

WITHDRAWING CONSENT

 

I understand that at any time, during the course of biofeedback/neurofeedback treatment, I may revoke my consent to biofeedback/neurofeedback treatment. 

 

 

FOR MINORS

 

CONSENT TO BIOFEEDBACK/NEUROFEEDBACK TREATMENT

 

I, the parent/guardian, have been informed about biofeedback/neurofeedback treatment purposes, methods and effects, including possible side effects.  I was given the opportunity to ask questions about biofeedback/neurofeedback, and any questions I asked were answered to my satisfaction.

 

I understand that at any time, during the course of my child’s biofeedback/neurofeedback treatment, I may revoke my consent for my child’s biofeedback/neurofeedback treatment.

 

I, the parent/guardian give my consent for my child to participate in biofeedback/neurofeedback treatment conducted by InMindOut Emotional Wellness Center, LLC staff.

 

 

The signature below indicates I have read the terms above. I consent to biofeedback/neurofeedback treatment and I understand that the treatment is voluntary and I may withdraw consent at any time.

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InMindOut Emotional Wellness Center https://inmindout.com
Signature Certificate
Document name: Consent to Biofeedback/Neurofeedback Treatment
Unique Document ID: 11f9397aa746dbdf7b5506b5a9300f94799075fa
Timestamp Audit
October 21, 2017 2:07 pm CSTConsent to Biofeedback/Neurofeedback Treatment Uploaded by Amanda Bergeron Bergeron - amanda.bergeron@inmindout.com IP 23.122.45.227
January 15, 2018 11:37 am CST Document owner amanda.bergeron@inmindout.com has handed over this document to imo@inmindout.com 2018-01-15 11:37:52 - 23.122.45.227