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BIOFEEDBACK & COUNSELING FORMS

We ask that you arrive 10 minutes early to your first appointment to fill out new client forms.
If you prefer, you may print out the necessary forms and fill them out in advance to avoid the need to arrive early.

For your first appointment with us (CONSULT), please fill out:

Note: This receipt confirms that you have received “NOTICE of Privacy Practices.” You do not need to print that out to give to us; it is made available for your information only. We also have paper copies of the Notice of Privacy Practices in our office that we can give to you

For a QEEG BRAINMAP, please fill out:

For an INTAKE appointment, please fill out:

Other Forms:

  • Authorization to Release Information If applicable, you may choose to authorize communication, such as sending your records, or discussion of your health information, between BiofeedbackWORKS and other health care providers who are treating or have treated you.