LENS Neurofeedback Preliminary Questionnaire

Name(Required)
Date of birth(Required)
Phone(Required)
Have you recently been hospitalized, treated in a psychiatric emergency department, or received psychiatric crisis care?
Are you currently experiencing a significant worsening of your psychiatric or emotional symptoms?
Are you currently in a psychiatric or medical crisis, or having thoughts of harming yourself or someone else?
Have you ever had a seizure or been diagnosed with epilepsy?
Have you ever experienced any of the following?
Have you received neurofeedback before?
If yes, did you have a difficult or concerning response?
Have there been any recent changes in your medications?

Acknowledgment

I confirm that the information I have provided in this questionnaire is accurate and complete to the best of my knowledge. I understand that this information is used to help determine whether LENS neurofeedback can be appropriately scheduled and that I should inform the provider if any of this information changes.
Agreement(Required)
Name(Required)
Date(Required)