LENS NEUROFEEDBACK
APPOINTMENT REQUEST
Patient Name
First Name
Last Name
Patient Date of Birth
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Month
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Day
Year
Date
Gender
Please Select
Male
Female
Address
Street Address
City, State, Zip
E-mail address
E-mail address
Phone Number
Format: (000) 000-0000.
Presenting Concerns (Check all that apply)
Depressed mood
Racing thoughts
Excessive worry
Unable to enjoy activities
Impulsivity
Anxiety attacks
Sleep Disturbances
Brain Injury/Concussion
Avoidance
Memory Issues
Anxiety
Emotional Regulation
Concentration/forgetfulness
Headaches/Migraines
ADHD/Focus Issues
Autism Spectrum
PTSD/Trauma
Excessive guilt
Increased irritability
Fatigue
Crying spells
Sensory Sensitivites
Brain Fog
Other
Are you currently seeing a talk therapist?
Yes
No
Have you received neurofeedback or biofeedback in the past?
Yes
No
On average, how many hours do you sleep per night?
Do you struggle with:
Falling Asleep
Staying Asleep
Nightmares
Do you experience:
Racing Thoughts
Trouble Focusing
Mood Swings
Panic Attacks
Brain Fog
Impulsivity
Daily Functioning: Are your symptoms affecting your:
Work/School performance
Relationships
Daily Tasks and responsibilities
Motivation
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-2pm
Tuesdays 8am-2pm
Wednesdays 8am-2pm
Fridays 8am-2pm
Saturdays 8am-3pm
Monday-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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