Please sign and date form below.
While I am aware and accept that no guarantees about the results have been made, the Direct Neurofeedback system has been shown in clinical use to reduce symptoms in a wide range of conditions, including: anxiety, depression, post-traumatic stress disorder, ADD, substance abuse, autism and traumatic brain injury. Direct Neurofeedback has also been found to result in improvement in athletics and other areas or performance. Direct Neurofeedback is not a medical treatment and is no substitute for effective standard medical treatment. If medical treatment is necessary, you agree to seek it if encouraged to do so.
While the long-term effects of electromagnetic feedback as we use it is unknown, for reference, a double AA battery held against the forehead is at least 1,000 times stronger than the Direct Neurofeedback signal. Earlier versions of technologies similar to Direct Neurofeedback have been in existence since the early 1990’s, yet we are not aware of any reports of someone being worse from having completed a course of treatment using Direct Neurofeedback.
Temporary side effects, especially early on, are not uncommon. In early sessions it is common for the brain to be overly “reactive” or get overly stimulated. The four most common “side effects” are a. Tired b. Wired (easily excitable) c. “Spacey”, or lightheaded d. Headache
These side effects are usually mild and typically last from minutes to hours, occasionally for a day, and very rarely for up to a few days. They are always temporary.
There may also be a temporary change in sleep with more vivid dreams.
It is possible to have a temporary flare-up of presenting symptoms.
It is possible that anything you have experienced in the past, including anxiety, tics and even physical discomfort may temporarily return. These experiences are always temporary, typically lasting from a few minutes to a few hours and rarely up to a few days.
I understand that if I do experience side effects, that in subsequent sessions modifications will be made so that side effects will be absent or reduced. Like giving medication, the dosage often needs to be adjusted, sometimes several times, based on response.
There have been reported seizures in those who have had prior seizures. However, Direct Neurofeedback appears to act as an anticonvulsant and has led to medically supervised decreases in anticonvulsants.
While Direct Neurofeedback can be used to treat migraines, it also possible to provoke a migraine.
I understand that I am a voluntary participant and may withdraw my consent and discontinue sessions of Direct Neurofeedback at any time.
Initial improvements are temporary, but with additional treatment these improvements typically last longer and longer until they are more “enduring”. We do not guarantee full or permanent resolution of symptoms. Some clients need “tune-ups”, or additional sessions. Because improvements are initially temporary, I understand that if I do not complete a full course of sessions that initial improvements are not likely to continue.
I also understand that most people typically require about 20 sessions but that this number can vary. In some conditions, including autism, severe stroke or traumatic brain injury, certain learning disabilities, etc., patients may require more sessions that can continue for years.
I have been advised that I should avoid making changes in my medications without the express written approval of my medical doctor. Further, I understand that I have been advised of the importance of advising my Neurofeedback clinician or technician of any/and all change[s] in medication and/or dosage.
I acknowledge that I have read and understand this consent form and that the clinician or technician has fully answered all my questions to my satisfaction. I authorize The Dubin Clinic and associates and assistants, to perform Direct Neurofeedback sessions.
I acknowledge and agree that I have been given an opportunity to ask questions regarding Direct Neurofeedback and that these questions have been answered to my complete satisfaction and I hereby consent to evaluation and application of Direct Neurofeedback as discussed hereinabove. I understand that The Dubin Clinic is specifically for the practice of Direct Neurofeedback and is not engaged in the practice of medicine.
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