I acknowledge my (or my child's) participation in the EEG Neurofeedback Program (a form of biofeedback) at A Chance To Grow (ACTG). It addresses conditions that may relate directly with unbalanced brainwave activity. Symptoms of these conditions may include hyperactivity and Attention Deficit Disorder, specific learning disabilities, behavioral issues, certain sleep issues, depression, anxiety, chronic pain and headaches along with a variety of other symptoms. Irregular brainwave activity may also be associated with minor head injury.

Through our NeurOptimal® software program, information is captured about an individual's brainwave activity. The data is then mirrored back to the client while in session. This invites the brain to begin the process of regulating its rhythms, creating more of some frequencies and less of others. By addressing the brain's circuits, Neurofeedback helps to calm the Central Nervous System, moving it from rigidity, repetition and reactivity to one of flexibility, stability and creativity.

I understand that Neurofeedback is not a medical treatment, device or methodology. It is not used to diagnose medical disorders nor is it used as a medical treatment for disorders and has not been approved for any medical purpose by the FDA, Health Canada or any other governing agency. The use of NeurOptimal® is solely as a tool for brain training and optimization and not as a means of diagnosis or as a medical intervention. By signing this form, I agree that I am satisfied with the information I have been provided (verbal, written or otherwise) by my technician on the effects I can expect during my NeurOptimal® training and my questions have been answered to my satisfaction. I understand that it is not possible to predict how my (or my child's) Central Nervous System will react and there can be no guarantee as to the results of my (or my child's) training. I agree to cease training if I am less than happy with the results I am getting. I understand NeurOptimal® is purely a source of information and does not direct the response of the Central Nervous System. Consequently, I agree to not hold Zengar (NeurOptimal®) Institute Inc. or ACTG responsible for a less than desired outcome or any outcome that may be considered negative.

Furthermore, the individual (or parent/guardian) is aware that Neurofeedback is designed to stimulate activity in the brain (blood flow, glucose metabolism, and electrical activity) and that my (or my child's) dosage of medication (if applicable) should be monitored by her/his physician to prevent over stimulation.

By signing this form, I also permit ACTG to administer various assessment instruments including an EEG QuickScan. The individual (or parent/guardian) further agrees that ACTG may consult with my (or my child's) primary care practitioner and/or specialist with regard to the training and the results obtained. The parent/guardian further agrees that the data obtained in connection with the training may be used to further the research into the benefits of EEG through publications and presentations of results, with protection of the privacy and preservation of the anonymity of the participant. The individual (or parent/guardian) further agrees to submit any dispute with ACTG to binding arbitration under the rules of the Better Business Bureau, if applicable, or of the American Arbitration Association. This consent is valid for the term of my (or my child's) participation in the EEG Neurofeedback program.

I have read and understand the above consent and give permission for myself (or child) to have the opportunity to participate in the EEG Neurofeedback program.