INFORMED CONSENT

Name

authorize BrainGain SRQ to provide me with Neurofeedback Training and/or tPBM which are used for a variety of conditions which appear to be associated with patterns of brain activity. These adjuncts to therapy are recommended on the basis of empirical observation of improvement with clients with similar conditions. Published research shows improvements with ADD/ADHD, dementia, substance abuse, depression, anxiety, sleep, migraines, Alzheimer’s/Dementia, Parkinson’s disease, long COVID, PTSD, Migraines, TBIs and Autism when these approaches were utilized.

I understand neurofeedback (EEG biofeedback) requires placement of sensors on my scalp for the purpose of recording my EEG. This signal is used to provide video display and audio signals. I understand that training may affect my body’s response to medications and that prescribed medications may slow progress. Although some people have been able to reduce or eliminate medication after neurofeedback or tPBM, I understand I should not stop or alter taking prescribed medications without consulting my physician/psychiatrist. Should new symptoms develop, it is my responsibility to inform my health care providers, including my neurofeedback practitioner.

Photobiomodulation (PBM) has been shown through research to improve mitochondria function, increase cellular growth, repair and rejuvenate cells, improve blood flow and oxygenation, and reduce inflammation. Despite PBM's ability to promote cell growth, studies have not shown it to cause cancer. Studies suggest PBM may inhibit some cancer cells. It has also been found to enhance the viability of non-cancerous cells, helping to protect cells from treatment-related toxicity. PBM is currently being used successfully as an adjunct to cancer treatment and helps to manage side effects. Further research is needed to ascertain optimal dosages, wavelengths and treatment protocols. Approval by a qualified medical professional is recommended when there is a diagnosis of cancer.

I understand that training is based on client input and the effects on my autonomic nervous system. It is my responsibility to monitor and submit a report of any perceived effects of neurofeedback training/tPBM the day after each session. In addition to the 24 hour report, feedback includes any changes noticed by you or others after training begins. Though progress is reported by most recipients of neurofeedback and tPBM, no representation is made that any individual client will improve with training. Although some people notice initial improvements, training effects may not begin to show until 10-20 sessions. The training is noninvasive and no known harmful effects have been reported.

Cancellations are to be made by phone. I understand that if I don’t notify the office of BrainGain SRQ of any cancellations by phone at least 24 hours in advance, I will be charged for the missed session. There are no refunds on prepaid sessions or packages. Sessions purchased as part of a package expire one year from the date of purchase and are non-refundable. By signing this form, I understand the information set forth here and waive any claim of damages due to the training, including worsening of the condition for which the training was undertaken, claimed side effects or the failure to improve with training.

I agree that comments on my 24 hour reports may be used anonymously as testimonials.

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Signature

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Release of Information:

I authorize Amy Warren, LMHC to communicate any relevant case information, symptoms and obtained results with my medical and/or mental health providers.

List any medical and mental health providers with whom you consent to the release of information:

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Amy Warren, LMHC | BrainGain SRQ | 1266 First Street, Suite 2, Sarasota, 34236 | (941)780-1000