Echo Rock Neurotherapy Intake Form
My appointment is with:
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Name *
Name of parent (if under 21)
Age
Birthdate
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Sex
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Address
City, State, Zip Code
Cell Phone *
Email (for your results) *
I can be most easily reached by
Profession/School
Professional Title/School Grade Level
Where did you hear about us specifically? (i.e: search words used, name and business of person who referred, event name)
Current Medical Issue Diagnosis
Doctor/healthcare practitioner name and #
Medical Insurance Carrier (for superbill)
Have you had neurofeedback/brain stimulation before?
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If so, explain type:
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