getparamounthealth.com - ExoMind Client Intake & Consent Form

ExoMind Client Intake & Consent Form
Date:

MonthDayYear
Date
Name:

First NameLast Name
Age:
Sex:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone (Cell):
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Occupation:
Employer:
Emergency Contact:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Referred By:
Relationship:
What brings you in today?
What are your top goals for care?
HEALTH & WELLNESS BACKGROUND
Have you ever received counseling, therapy, or neurotherapy before?
If yes, please describe:
Please check any symptoms or areas of concern you currently experience or have in the past 6 months:
Current Medical Diagnoses:
Current Medications or Supplements:
Have you been hospitalized for mental or physical health?
If yes, when and why?
Lifestyle Factors:
Exercise frequency:
Sleep quality:
Substance use (alcohol, tobacco, etc.):
Caffeine or stimulant use:
Major life stressors (work, family, financial, etc.):

Please circle YES or NO for the following:

Rows	YES	NO
Have you had thoughts of harming yourself or others?
Have you ever attempted suicide or self-harm?
Do you currently feel unsafe or at risk of harming yourself?
Do you experience hallucinations or hear voices?
Do you have extreme mood changes or manic episodes?
Do you use alcohol or drugs to cope with emotions or stress?
Do you have a history of seizures, head trauma, or brain injury?

If you answered YES to any of the above, please explain:
INFORMED CONSENT FOR EXOMIND SERVICES

ExoMind provides noninvasive neurotherapy and mental wellness services designed to support the nervous system and promote emotional balance. I understand that these services are not a substitute for medical or psychiatric treatment.
Contraindications (Please check all that apply):
Potential Side Effects

Possible temporary side effects may include mild headache, fatigue, muscle twitching, or dizziness. Serious side effects such as seizure are rare but have been reported in clinical literature.

Acknowledgment

I understand the potential risks, benefits, and alternatives to this therapy and have had the opportunity to ask questions.

By signing below, I acknowledge that:
- I have disclosed all relevant medical history.
- I understand the purpose and nature of the services provided.
- I consent to participate in ExoMind sessions under the direction of my provider.
Client Name:
Client Signature:
Date:

MonthDayYear
Date
Should be Empty:

ExoMind Client Intake & Consent Form