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