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Sign up for a 15-minute free consultation
MAGIS Therapies and Mindworks Neurofeedback Center is currently offering 15-minute free online consultations for those who need support and/or would like the opportunity to try Neurofeedback / Brain Mapping.

Please be informed that this is different from the Brain Map Assessment itself and this consultation is only to understand the client's concerns and if they would benefit from the service. 

To help us serve you in the best way possible, please provide the information below.

Please note that this is not a 24/7 hotline.
In case of emergency, or if you think your life or someone else's life is in danger, please call:
DOH-NCMH Hotline:
0917-899-USAP (8727)
0917-989-USAP (8727)
Or go to the nearest hospital within your vicinity.

All information provided is kept strictly confidential.

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Email *
For MINOR clients, the guardian filling out this form should put the information of the minor client. From items asking for their name up to the medications, all information should be the minor client's. *
First Name *
Last Name *
Nickname *
Age *
Date of birth *
MM
/
DD
/
YYYY
Gender *
Civil status *
Complete address *
Email address *
Contact number *
Choose which branch you prefer to schedule an appointment with: *
Description of the problem or general concern *
You may be as detailed as you wish. Kindly note as well if you have been given a diagnosis and when have you been diagnosed by a developmental pediatrician or a psychiatrist.
Are you aware of what could be triggering your concern? *
Please write what triggers your concern and/or when does it happen.
How long has this been a problem for you? *
Please write when did you think your concern has started and how long has it been an issue for you.
How often does your concern takes place? *
If the frequency doesn't match with the choices below, you may be as detailed as you wish by choosing "other".
Have you sought therapy or interventions before? *
If you answered yes from above, please write the interventions you did in the past. If no, kindly put NONE. *
Are you taking any psychotropics medications for your concern? *
If you answered yes from above, please enumerate ALL psychotropic medications you are currently taking. *
Kindly include name, dosage, frequency, and when did you last take it. (Ex. Xanax, 0.5g, as needed, took it last night at 8PM)
Is it your first time to seek Neurofeedback / Brain Mapping? *
How did you learn about Neurofeedback? *
IN CASE OF EMERGENCY, PLEASE CONTACT:
To support you to the best of our capacity, please include an emergency contact.
Full name of emergency contact *
Emergency Contact's complete address *
Emergency Contact's contact number/s *
Emergency Contact's relationship to you *
ACKNOWLEDGEMENT
I certify that the information provided in this form is true. *
Required
A copy of your responses will be emailed to the address you provided.
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