LENS NEUROFEEDBACK

LENS NEUROFEEDBACK

APPOINTMENT REQUEST
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Gender
Address

Street AddressCity, State, Zip
E-mail address

E-mail address
Phone Number
Format: (000) 000-0000.
Presenting Concerns (Check all that apply)

Depressed moodRacing thoughtsExcessive worryUnable to enjoy activitiesImpulsivityAnxiety attacksSleep DisturbancesBrain Injury/ConcussionAvoidanceMemory IssuesAnxietyEmotional RegulationConcentration/forgetfulnessHeadaches/MigrainesADHD/Focus IssuesAutism SpectrumPTSD/TraumaExcessive guiltIncreased irritabilityFatigueCrying spellsSensory SensitivitesBrain FogOther
Are you currently seeing a talk therapist?

YesNo
Have you received neurofeedback or biofeedback in the past?

YesNo
On average, how many hours do you sleep per night?
Do you struggle with:

Falling AsleepStaying AsleepNightmares
Do you experience:

Racing ThoughtsTrouble FocusingMood SwingsPanic AttacksBrain FogImpulsivity
Daily Functioning: Are your symptoms affecting your:

Work/School performanceRelationshipsDaily Tasks and responsibilitiesMotivation
What are your top 2-3 goals for LENS Neurofeedback? (e.g., better sleep, reduce anxiety, increase focus)
We are located at 4646 Poplar Avenue in Memphis, TN. Select the appointment window/windows that would fit best for your schedule. Appointments are approximately 30 minutes long. I will reach out to discuss and confirm an appointment within 24-72 hours.

Mondays 8am-2pmTuesdays 8am-2pmWednesdays 8am-2pmFridays 8am-2pmSaturdays 8am-3pmMonday-Saturday 4pm-6pm
LENS Neurofeedback costs $125 for the initial appointment and $70 for each visit after that. Insurance sometimes covers LENS Neurofeedback, but it's not guaranteed. The fastest way to get an appointment is thru self-pay. Will you be using insurance or will you be self-pay? (If using insurance, please list your insurance company)
My name is Krystle Smith, and I will be your LENS Neurofeedback technician. If at anytime you have any questions, please feel free to e-mail me at Krystlesmith@forwardcounseling.com. I check my email everyday and am here to answer any questions that you might have. I'm leaving this space here for you to tell me anything you might like me to know before our first session. I look forward to meeting you soon :)
Consent & Agreement Section

I understand that LENS Neurofeedback is not a diagnostic tool.I understand that results may vary from person to person.I consent to participate in LENS Neurofeedback sessions.I understand that this is not a replacement for medical or psychiatric care.
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