Neurofeedback Intake Form Please provide the following information and answer the questions below. *For couples or families, you may fill out only one form if preferred. Date: Name: Last First DOB: Age: Name of parent/guardian (if under 18 years): Last First DOB: Age: Marital Status: Never MarriedCommon LawMarriedSeparatedDivorcedWidowed Please list any children, age, and relationship Guardianship Agreement (no guardianship,sole, or shared) Name/Contact info of guardian holders Address: City: PC: Contact Information: Home Phone: May we leave a message?YesNo Cell/Other Phone: May we leave a message?YesNo E-mail: May we email you?YesNo *Please note: Email correspondence is not considered to be a confidential medium of communication. Hours of Availability: Monday 9am10am11am12pm1pm2pm3pm4pm5pm6pm7pm8pm Tuesday 9am10am11am12pm1pm2pm3pm4pm5pm6pm7pm8pm Wednesday 9am10am11am12pm1pm2pm3pm4pm5pm6pm7pm8pm Thursday 9am10am11am12pm1pm2pm3pm4pm5pm6pm7pm8pm Friday 9am10am11am12pm1pm2pm3pm4pm5pm6pm7pm8pm Other: Financial Information: RCC Staff Rate: (Rate Based on combined household income) Counselling Intern Rate: (Rate Based on low income and no benefits to cover) Insurance Coverage: Insurance Carrier: Sponsored By: Counsellor RCC# How did you hear about Cares? Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? No Yes, previous therapist/practitioner Type of Treatment Are you currently taking any prescription? No Yes (Please list) Have you ever been prescribed psychiatric medication? No Yes (Please list and provide dates) 1. Do you currently experience overwhelming sadness, grief or depression? NeverRarelySometimesOftenAlways If yes, when did you begin experiencing this? 2. Do you currently experience anxiety, panic attacks or have any phobias? NeverRarelySometimesOftenAlways If yes, when did you begin experiencing this? 3. Have you experienced a traumatic brain injury? NoYes If yes, please describe? 4. Have you experienced or are you currently experiencing events that you consider to be mentally, emotionally, and / or physically traumatic? NoYes If yes, please describe? Additional Infomation 5. Are you currently employed? NoYes If yes, what is your current employment situation? Do you enjoy your work? Is there anything stressful about your current work? 6. Do you consider yourself to be spiritual or religious? NoYes If yes, describe your faith or belief 7. What would you like to accomplish out of your time in therapy? **Please remind clients that Cares is a scent-free environment** CHECKLIST OF CLIENT CONCERNS Name: Date: PRE/ONGOING/POST DATE: Below is a list of problems that clients frequently describe to us. Please check off any that match your current concerns. If you are not sure whether to endorse an item, use the past week as a guide. Feel free to add any comments as necessary. Thank you. Immune System AllergiesAsthmaFrequent colds, infections,Yeast infectionsFatigue Sleep Difficulty falling asleepWakeful or restless during nightWaking up earlyDifficulty waking upNightmares or night terrorsSnoringSleep walking Skin/Hair/Nails Problem with skinHairNails Eyes Double or blurred visionBlind spotsSpots in your vision Ear/Nose/Throat Hearing lossRinging in earsEarachesSense of smell changed or lostNose or sinuses blockedGrinding your teethSense of taste changed or lostHoarseness or sore throat Heart/Lungs Problems breathingHeart problemsHypertensionPalpitationsDizzinessDifficulty organizing activatesNot completing tasksLose train of thought Intestines Nausea or vomitingGastric painGas or bloatingIrritable BowelDiarrheaConstipationAppetite problems (e.g. wanting to eat when not hungry, etc) Hormonal/Blood DiabetesDesire for sweets or carbohydratesSensitivity to heat or coldThyroid problemsPMS symptomsHot flashesOther menopausal symptomsLow interest in sexExcessive interest in sex Bones/Joints/Muscles Pain or stiffness in joints or musclesSore trigger pointsFibromyalgiaBodily fatigue Nervous System headaches or migrainesFaintingSeizuresMemory lossBlocking on wordsReading problemsDifficulty speakingTremor (shaking)WeaknessHyperactivityProblems with balanceMotor or vocal tics Attention and Organization Difficulty focusingEasily distractedDifficulty organizing activitiesNot completing tasksLose train of thought School/Learning Difficulty completing schoolworkGetting into trouble at schoolInverting letters/numberSpatial problems (e.g. difficulty building things, understanding how things should be put together)Difficulty with particular subjects Bowel/Bladder Difficulty urinatingDifficulty holding your urineDifficulty controlling your bowelsFrequent bladder infections Habits Sometimes drink too muchSmoke cigarettesConcerns about your dietDesire CaffeineUse marijuanaOther addictions Behaviour/Emotions Mood swingsFeeling down, depressed or flatFeeling sadFeeling anxiousPanic attacksWorryThoughts that won't leave your mindNeed to repeat actions or words over and overBingeingRestricting your food intakeMaking yourself vomitPhobias- avoiding thingsFeeling others are against youBehaviors that get you into trouble, or are not good for youFeeling angry a lotImpulsiveFeeling overwhelmed TRAINING AND FEE GUIDELINES AND DISCLOSURE Please read the following carefully. If you decide to receive NeurOptimal® training with us, these policies will guide our work together. 1. Fees are due at time of service. Fees are paid at each session or in advance. We do not work with insurance or submit to third parties. We will give you a receipt and you can seek reimbursement as you see fit. 2. Session length is about 50 minutes, so you will typically be in and out within the hour. It is not a problem if you arrive late, but the session will need to finish at its appointed time. We will work with you to provide the maximum training time we can in the time we have. 3. We have a 24-hour cancellation policy.If you cancel less than 24 hours before the start of your session, we ask you to be financially responsible for the session. This means you need to call before 24 hours before the start of the consideration. While we can-and do- feel personally sympathetic to issues that can arise, please consider your booking like a concert ticket. Feel free to use it or not, as supports your best interests at the time. 4. We do not provide emergency coverage and may not be available for blocks of time, such as weekends or holidays. You are welcome to call us between 8:30 am and 4:00 pm any day of the week or email at any time (cares.info@gmail.com) and we will get back to you as soon as we are able. Please sign below that you have read, understood and are able and willing to work within these guidelines. Your Printed Name: CLIENT INFORMED CONSENT I, understand that NeurOptimal® is not a medical treatment, device or methodology. It is not used to diagnose medical disorders nor is it used as a medical treatment for disorders and has not been approved for any medical purpose by the FDA, Health Canada or any other governing agency. While Zengar trainers may or may not be licensed health care practitioners, their use of NeurOptimal® is solely as a tool for brain training and optimization and not as a means of diagnosis or as a medical intervention. I am satisfied with the information I have been provided (verbal, written or otherwise) by my trainer on the effects I can expect during my NeurOptimal® training and my questions have been answered to my satisfaction. I understand that it is not possible to predict what my central nervous system will do with the information it is offered and consequently there can be no guarantee as to the results of my training. I agree to cease training if I am less than happy with the results I am getting. I understand NeurOptimal® is purely a source of information and does not direct the response of the central nervous system. Consequently, I agree to not hold Zengar Institute Inc or any of its users and trainers responsible for a less than desired outcome or any outcome that may be considered negative. Your Printed Name:
