Consent to Receive Biofeedback Training from the Quantum Biofeedback Wellness Center, Inc

Disclaimer. I fully understand that the attending practitioners are not licensed as a chiropractor,counselor, medical doctor, psychologist or psychotherapist and does not portray themselves as such. I understand that the attending practitioners will not diagnose, evaluate, treat, cure, mitigate or prevent any nutritional, medical or psychological disease, disorder or condition. I further understand that the attending practitioners will not advise, recommend, suggest or counsel me on any medical, dietary, emotional or psychological treatment, condition, disorder or disease of any kind. I further understand it is my responsibility to continue my medications and remain under the care of my primary physician.

Credentials. I understand that the attending practitioner is a Certified Quantum Biofeedback Specialist and that she will train me with biofeedback for relaxation and muscle re-education so I can learn to reduce my stress, manage my pain, and improve the quality of my life. I further understand that the attending practitioner will refer me to qualified experts for any other concerns I have about my health and wellness.

Scope of Biofeedback Practice. I understand the intended purpose of biofeedback training is for relaxation and muscle re-education so I may learn to: 1) reduce my stress, 2) manage my pain, and/or 3) improve the quality of my life. I understand biofeedback training is generally considered safe, but it is possible that biofeedback may exacerbate some emotional problems or I may become drowsy, at least temporarily, during the biofeedback training sessions. Other potentially harmful side effects not yet reported may occur. I agree to advise the attending practitioner anytime I feel any side effects, so corrective steps may be taken to alleviate my discomfort.

I further understand biofeedback is not a substitute for effective standard medical, chiropractic or psychotherapy treatment or veterinary treatment for my pet. The attending practitioner has advised me to continue ongoing medical treatment and therapies until otherwise advised by my psychotherapist, physician, or medical practitioner. I understand it is important for me to stay in close communication with my physician.

I understand it is my responsibility to monitor the effects of biofeedback training and to continue the training as long as long as it is beneficial to me. I will tell the attending practitioner anytime I experience any discomfort during biofeedback training. I further understand that research suggests that while most people gain considerable benefits from biofeedback training, some people may not gain any benefit. I have every expectation that biofeedback will provide me some benefit, but I understand there is no guarantee that it will.

Confidentiality. I understand my identity and any information about me, whether I share it with the attending practitioner or she discovers it on her own, will be held in the strictest confidence, except when released by me or specifically required by law. I have the right to waive this confidentiality agreement in whole or part at any time. I also understand that I may give the attending practitioner permission in writing to contact my primary care practitioner or specialist with regard to the training provided by her and the results I obtain. I have the right to withdraw this permission at any time.

Client is a Child. If the undersigned is the custodial parent or legal guardian of a child and is seeking to have a Biofeedback session for said child, then said custodial parent or legal guardian hereby grants the attending practitioners express consent to give a biofeedback session to said child and undertakes all of the above representations on behalf of said child. Said custodial parent or legal guardian hereby further agrees to indemnify attending practitioners for, and to hold them harmless from all damages and costs, including reasonable attorney’s fees, resulting from any absence of or defect in said custodial parental or legal guardianship relationship.

Payment for services. I agree to pay the Quantum Biofeedback Wellness Center, Inc by check, money order, cash, or credit card (Visa/MasterCard) for each biofeedback session. In the event my check bounces, I agree to pay full restitution plus an additional fee as a penalty.

Arbitration. I agree that in the event Quantum Biofeedback Wellness Center, Inc and I are unable to reach an amicable solution to any issues between us, we both agree to accept the decision of the attorney arbitrator of the Natural Therapies Arbitration Council as the final settlement of our differences. I understand this service is provided through the Biofeedback Association of North America (800-985-0819) at no cost to me. I further understand that if the arbitrator finds against me, I will not be required to pay a penalty above whatever amount the arbitrator finds equitable.

Client Warranty. By signing below, I acknowledge that I have read and understand this document, and have received acceptable answers to all of my questions about biofeedback services. I consent to receive biofeedback training from the attending practitioner at the Quantum Biofeedback Wellness Center, Inc. I warrant I am not under duress at this time and my consent is given voluntarily and without coercion. I further understand I may discontinue biofeedback training at any time and that I may refuse to participate in any particular or specific biofeedback training without penalty.

Client Signature _____________________________Date __________