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Welcome to Clear Mind Center of Utah/Clear Mind Utah. The purpose of this form is to obtain your voluntary consent to participate in one or more methods of: Micro Current Neurofeedback (MCN); infra-red-light therapy; other forms a relaxation and stress reduction interventions, and exams of your nervous system and brain; and to disclose potential benefits and risks associated with these interventions.

Clear Mind Utah provides various educational interventions, assessment protocols, and mental wellness services, a few of which are still considered by some to be experimental.

BENEFITS OF NEUROFEEDBACK

The IASIS MCN: Micro Current Neurofeedback system has been shown in clinical use to bring about significant improvements in a relatively brief process of therapy in physical and emotional rehabilitation. Significantly shorter rehabilitation is of great importance in time, money, and client hopes. You may experience an end to the problems affecting you since your head injury and/or psychological trauma, and to the problems that have interfered with your ability to function in your work and personal life.

The return of clarity, energy during the day, sleeping at night, a sense of humor, motivation to get things done, ease of getting things done, memory, ability to read and listen with little or no distraction, and the absence of depression, irritability, impatience, and explosiveness have been observed repeatedly.

The FDA recognizes that all interventions pose risks and benefits. Typically, the benefits of neurofeedback far outweigh the risks. Neurofeedback is known to assist individuals by decreasing symptoms associated with brain and central nervous system dysfunction. Occasionally it can result in non-serious adverse events. As a form of biofeedback, it falls under the category of other low-risk activities such as progressive relaxation, hypnosis, breathing exercises, meditation, yoga, and massage. The benefits are usually experienced as improved focus, enhanced concentration, increased energy, higher quality sleep, decreased moodiness, diminished agitation, reduction in anxiety as well as reductions in other physical symptoms typically related to stress such as headache. Other benefits include the possibility of reducing problem behaviors and increasing peak performance. In many cases, neurofeedback is considered to be experimental when used to train certain disorders. Please feel free to ask for a more detailed explanation regarding your problem area.

IASIS MCN may help us further understand and or confirm the problems or symptoms, disorders, and or diagnosis for which you are seeking assessment and healthcare services. Many clients have observed improvements with conditions such as ADD, ADHD, Alzheimer’s, Anxiety, Anger, Autism, Brain Fog, Chemo Brain, Chronic Fatigue, Epilepsy, Fibromyalgia, Insomnia, Lyme Disease, Migraines, Parkinson’s, Depression, PTSD, Stroke, MS, Memory, Peak Performance, and others. IASIS Microcurrent Neurofeedback does not specifically target any disorder. It changes the timing and activation patterns in the brain. The goal is to untrain the brain from its faulty patterns so it can return to normal, healthy patterns and reconnect neural pathways that have been disconnected. Symptoms improve as a result of improved brain regulation.

THE IASIS MCN: MICROCURRENT NEUROFEEDBACK PROCEDURE

In the MCN process, electrode gel or cream will be applied to the skin on certain sites on the head. There will be sensors attached in front or behind the ears, to provide a connectivity reading. A sensor will be placed on the neck as a reference or ground, and two additional sensors are placed on various sites on the scalp, providing micro doses of stimulation. No invasive procedures are used.

The equipment assesses a client's brainwaves -- extremely faint electrical signals measured at discrete locations on the scalp. After a short assessment of these brainwaves by a provider, the equipment itself then generates extremely faint, battery-generated signals that the brain may respond to in beneficial ways.

During the sessions you will be asked to sit quietly. You will not be asked to think of anything, or to learn anything. In fact, you will be asked to not think of any imagery or constructive thoughts. We have found that this can slow therapy progress. Your brain can detect the feedback, although you will not see or feel anything.

You will be asked to keep track of discomforts or side effects experienced during your therapy. You will also be asked about your most prominent symptoms before therapy and how they change. DURATION You may have as many sessions as you need, each session lasting between one second and several minutes in duration. The rest of the time will be spent, as needed, talking about what effects, if any, the feedback has had on you. The initial session may take 45-60 minutes in total or shorter as needed. Follow up sessions may take 15-60 minutes.

It is difficult to predict how many IASIS MCN: Micro Current Neurofeedback sessions will be required. The following estimates are based on our experience; some clients have needed fewer sessions, and occasionally a few more:

If your problem came on suddenly after a life of high functioning and you are comfortable with the longer periods of feedback, you can expect 15-20 sessions. This is only an average range; however, therapy may require more or less than the average figures.

If you have a lifelong history of multiple problems, you may need many more sessions.

INFRA-RED LIGHT THERAPY

Infra-red light therapy is also known as low-level laser therapy (LLLT) and has a long history of showing benefits for many different health issues. It has been shown to have many benefits when performed over the skull/brain as well as other parts of the body such as decreased inflammation, increased circulation to the area, and cellular repair. You have the right to decline or accept these sessions. You have the right also to ask questions about the efficacy of these sessions. You also have the right to ask for references regarding low-level laser therapy over the skull.

SIDE EFFECTS AND RISKS

Training with neurofeedback can occasionally result in adverse responses that temporarily increase symptoms which are typically associated with relaxation and calming of the central nervous system such as fatigue, headaches, lightheadedness, dizziness, irritability, moodiness, weeping, insomnia, agitation, and difficulties with focus and anxiety. These reactions, if they occur, are temporary and typically last only 24 to 48 hours. Once clients or clients become more relaxed and aware, they tend to integrate past emotional issues and these symptoms subside. Neurofeedback will not interfere with most other therapies.

Neurofeedback has few side effects when administered properly. The most common side effects of neurofeedback include improved sleep, more awareness of dreams, feeling calmer, feeling more energy, and feeling more focused. It is also possible that you might fall asleep during or after neurofeedback sessions.

It is important to note that neurofeedback decreases the need, in many cases, for psychotropic prescription drugs. If you are taking one of those drugs, you must be aware that you will need to discuss decreasing your dose with the doctor who prescribed the drugs as the need for those drugs goes away. Otherwise, you may start to have symptoms that would be normally associated with taking drugs you don't need.

Electromagnetic Field Side Effects:

The intensity of IASIS Micro Current Neurofeedback field is less than three trillionths of a watt, or 3 picowatts, and less, and is on for a few seconds during each session. A background signal approximately a thousand times less than the feedback signal is also present as soon as the EEG begins to read the brainwaves. For reference, a cellular telephone generates a signal at least millions of times the power of the IASIS MCN: Microcurrent Neurofeedback feedback signal. Although the long-term effects of using electrical field feedback as we use it is unknown, no instances of problems with the emissions from the feedback have ever been recorded.

Seizures:

With very few exceptions, seizure activity has not been a primary reason to seek therapy with IASIS MCN: Microcurrent Neurofeedback. There have been reported seizures in those who have had prior seizures. However, IASIS MCN: Microcurrent Neurofeedback appears to act as an anticonvulsant and has led to medically supervised decreases in anticonvulsants.

One of the biggest sources of seizure is a sudden decrease in anticonvulsants by the client. We urge clients to consult their physicians before decreasing medications of any kind.

Brief Reactions:

There are some potential risks of discomfort involved in participating in this therapy. On the rare occasions when the feedback is too intense or the feedback periods are too long, you may feel uncomfortable, irritable, tense and anxious. This rarely happens for more than a second at a time. When this happens, please tell the operator and the settings on the equipment can and will be changed to make the feedback less intense and shorter in duration, to the extent that you are once more comfortable. The process may cause you to have mild discomfort or headache. We will provide suggestions to mitigate these possible effects. 

Longer Lasting Reactions:

You may experience one or two-week periods of anger, fear, and irritability during the therapy. You may feel as if you have tremendous energy to do things or feel very tired. These longer-lasting reactions have especially tended to occur with feelings that people have been struggling to control for a long time. While these feelings can be intrusive and bothersome, it has been the experience of previous clients that they can still function. At times however, support from your own therapist or physician may be useful and should be relied upon.

You must report any and all medications you use while you participate in the therapy and are not to change your medications without informing your therapist and your physician.

When is Something a Side Effect or a Benefit?

While we have had experience since 1990 with IASIS MCN: Micro Current Neurofeedback and its antecedents, and are familiar with many of its benefits and side effects, it is sometimes difficult to know when a feeling, benefit, or other problem is due to IASIS MCN: Micro Current Neurofeedback, or due to something else happening, such as an on-coming cold, allergy, a stress in your life, or some other kind of physical change in you, completely unrelated to IASIS MCN: Micro Current Neurofeedback. In addition, your own background can play a very big part in the kinds of feelings you have while receiving IASIS MCN: Micro Current Neurofeedback.

Here’s a guide for thinking out what a feeling, benefit, or problem is due to: If you find yourself wondering or guessing more than three times about why you are feeling something, it is probably due to either IASIS MCN: Micro Current Neurofeedback or another physical reason. If, on the other hand, you think you know why you are feeling the way you do, trust yourself.

You do not have to know whether something may be due to IASIS MCN: Micro Current Neurofeedback or whether it may be due to something else. If you notice something and wonder about why you are experiencing it, make note of it for later discussion with us. Please write notes about your feelings and questions, and bring them with you to your sessions.

A PERSPECTIVE ON SIDE EFFECTS FROM IASIS MCN: MICROCURRENT NEUROFEEDBACK:

Although the unexpected is always a possibility, we have always found that any side effects that have occurred in IASIS MCN: Micro Current Neurofeedback were already familiar ones. In other words, the feelings and medical problems that arose have always been something that the clients have experienced and have had some trouble with in the past.

Those whose medical status is unstable are advised to consult with their physician about becoming more medically stable before participating in this therapy. IASIS MCN: Micro Current Neurofeedback tends to lower blood pressure, which can complicate some kinds of problems such as orthostatic hypotension.

It is also important to know that when the problems have occurred during IASIS MCN: Micro Current Neurofeedback, many have been a fraction of their former intensity, which means that often they have been more manageable than in the past.

Your comfort is of great importance, so telling us your feelings at any time will help to reduce the side effects and make sure we can best cooperate with your therapist and/or physician.

Between Sessions:

While many people feel energy, ease, clarity, and happiness after an IASIS MCN: Micro Current Neurofeedback session, these positive feelings may precede feelings of fatigue, depression, and anxiety between sessions. Those “rebounding” from good feelings often feel discouraged and doubtful about their ability to finish therapy. The rebound appears to be the brain’s way of struggling to remain in the old, familiar, and dysfunctional state.

As people continue with IASIS MCN: Micro Current Neurofeedback, both the intensity of the good feelings and the unpleasant rebound periods tend to become shorter and less intense until the exaggerated feelings no longer occur. To date there have been no exceptions to this pattern.

Instead, people become clearer about the entire range of feelings they have, instead of staying numb and flat in their emotional responses.

Problem Cycles:

Relief from life-long problems can be uneven. The symptoms can feel sharper at times than they were before; they then pass and tend to rise less in subsequent cycles of rising and fallings. It has been our experience that during each cycle, both provider and person receiving this therapy can become anxious and filled with doubt about the wisdom of this therapy. It is important to know that no one has remained worse, and all but three percent have remained the same. The rest have improved. There is no guarantee that you will remain free from these problem cycles.

Considerations after Therapy:

It will be time to discontinue IASIS MCN: Micro Current Neurofeedback when you stabilize and achieve consistently better functioning. You may, however, become used to the stimulation that IASIS MCN: Micro Current Neurofeedback provides you, and go into a slump after you discontinue it. The slumps that have occurred have lasted between a few days and a month, and have been less of a problem than those that brought people into IASIS. MCN: Microcurrent Neurofeedback therapy. During this period your body will become accustomed to being open to its own internal useful stimulation. Most of those who have received IASIS MCN: Micro Current Neurofeedback have continued to improve long after IASIS MCN: Micro Current Neurofeedback has ended.

EQUIPMENT AND SOFTWARE

Micro Current Neurofeedback will involve the use of IASIS Technologies software and hardware.

OTHER METHODS

Other therapy methods may not work as rapidly as the methods and modalities described above. Alternative methods of therapy include traditional medical therapy, medications, the use of supplements, the use of relaxation techniques and group and individual therapy.

CLIENT RIGHTS REGARDING NEUROFEEDBACK. YOU HAVE THE RIGHT TO:

• Decide not to receive neurofeedback services from us. If you wish, we can provide you with the names of other qualified neurofeedback providers.

• End neurofeedback sessions at any time.

• Ask questions about protocols and procedures used during neurofeedback training and to ask questions about techniques if you feel unsure of them.

• Have all that you say treated confidentially and be informed of state law placing limitations on confidentiality in the neurofeedback relationship. Under certain circumstances we are required by law to reveal information obtained during training to other persons or agencies without your permission. Also, we are not required to inform you of our actions in this regard. These situations are as follows:

a) If you threaten bodily harm or death to yourself or another person, we are required by law to notify the victim and appropriate law enforcement agencies.

b) If a court of law issues a subpoena.

c) If you are being trained with neurofeedback at the direction of an attorney or medical doctor for legal purposes, the results of the training or tests must be revealed to the court.

d) If you have given us information concerning non-accidental injury and neglect to minors or incompetent adults.

e) If you are in the process of filing a worker’s compensation claim or file such in the future.

CHOOSING THE RIGHT INTERVENTION

Interventions described above are voluntary, not mandatory. You will not be pressured for not participating. You may withdraw from or stop receiving the neurofeedback training sessions at any time without consequences. If you have paid for one of our packages, you will be refunded for unused sessions AFTER CHARGES FOR PREVIOUSLY USED SESSIONS ARE DEDUCTED. Since you would no longer have a package which lowered the per session price, the used sessions will be calculated at the full individual cost of $150 per session and this retail value per session used will be subtracted from the amount you paid and the balance will be refunded to you within ten business days. I understand that:

1. Neurofeedback is not a quick fix or a cure-all but reduces symptom severity over time through training to improve central nervous system regulation.

2. The average number of neurofeedback sessions to achieve enduring change is 20 sessions.

3. On average, most people require 10 sessions to experience symptom changes. If symptom changes don't occur within 15 to 20 sessions it is due to either metabolic or personal relationship issues.

4. Side effects can result from prescribed drugs when dosage is not reduced over the sessions.

5. The chronic use of psychotropic drugs impedes progress.

6. Reducing dependence on Pharmaceuticals is a key objective of the training program.

7. Failure to notify your provider about changes in medication, changes in medication type, changes in dosages, taking new medications or stopping current medications may negatively impact the overall efficacy of neurofeedback.

8. Clients must make efforts to manage diet, exercise, sleep, and stressful activities to achieve the best results.

9. Failure to work with provider to make lifestyle changes can reduce or mitigate the effects of neurofeedback sessions.

VOLUNTARY PARTICIPATION

You are free to withdraw your consent and discontinue participation in the therapy at any time.

CONFIDENTIALITY

Your identity will not be disclosed without your separate consent, except as specifically required by law. Examples of legal requirements for breaking confidentiality are: under a court order; in case of unlawful behavior, such as suspected child abuse; or in case you bring legal action against the provider or the provider's staff. With these exceptions, any data released or published will not identify you by name.

If you cannot sign, through physical disability or illiteracy, but are otherwise capable of being informed and giving verbal consent, a third party, not connected with the therapy or next of kin or guardian may sign for you.

LIMITATIONS OF THIS CONSENT

This signed form may not be used as consent for any other therapy. Participation in any other therapy requires a separate form. All procedures performed under the protocol will be conducted by individuals legally and responsibly entitled to do so.

PERMISSION FOR THERAPY

I, a prospective client, give my full permission to Troy and Valerie Gundersen, supervisor, or other office staff to use any data collected during the preparation and participation in the IASIS MCN: Micro Current Neurofeedback sessions, and I give up all implied and actual ownership of any data collected. I understand that when data is used, my confidentiality will be protected and that my identity will not be revealed unless required by law (as outlined previously).

CONSENT

I voluntarily consent to participate in and undergo the assessment and or intervention methods and modalities described above. I understand that I am free to withdraw my consent and discontinue participation in the interventions, modalities, and methods. The natural consequences and potential risks and benefits have been fully explained to me by Clear Mind Center of Utah staff and personnel.

My electronic signature below indicates that I have read, reviewed, and understand this informed consent (and/or I have had the form and its contents read to me and explained to me) and I consent to participate in the procedures described above. I understand I may ask questions at any time and may request to stop interventions at any time. I have read and understand my rights. 

I agree and understand that by signing this Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

PAYMENT POLICY

Clear Mind Center of Utah is not contracted with any insurance companies and is not allowed to submit any claims directly to insurance companies on any client's behalf.

I understand that I am financially responsible for any charges incurred and must pay Clear Mind Center of Utah up front and in full the same day that I receive therapy or on an agreed upon payment structure set up by the Clear Mind Center of Utah Staff. If full payment is not made for services rendered, I understand that Clear Mind Center of Utah may be forced to take collection or legal action. I agree I will be liable for additional expenses, such as legal fees, interest on the unpaid portion of my account balance, and collection fees.

CLIENT RESPONSIBILITY TO CONTACT INSURANCE PROVIDER

I understand that it is my responsibility to contact my insurance carrier directly regarding any claims I would like to make and that I must submit these claims myself. I understand that any payments or reimbursements from my insurance company will come directly to me.

I understand that Clear Mind Center of Utah is not directly responsible for collection of payment from insurance companies and that all payments are to be made to Clear Mind Center of Utah.

Clear Mind Center of Utah does not accept any insurances and is a cash pay office, however, the office is willing to support you in submitting for reimbursements to your insurance. Clear Mind Center of Utah cannot be held liable for any undispersed insurance funds. Here are some things to note as you apply for reimbursements or appeals with your insurance company:

• Clear Mind Center of Utah does not work directly with insurance companies. We work with you and any other necessary parties involved to submit your paperwork.

• We encourage you to check in with your insurance provider to see if they cover our services. They will likely request both CPT and Diagnosis Codes. If you do not have a diagnosis or if, for some reason, we are unable to provide you with one, there is some likelihood of your services being covered with the CTP Codes alone. They are as follows:

90901 Biofeedback/Neurofeedback

• Developing the paperwork necessary for a reimbursement can take time. Please be aware that this paperwork may not be ready for submission until after completion of your services at Clear Mind Center of Utah.

• Clear Mind Center of Utah requires payment up front for all services or on a previously agreed upon payment structure set up by Clear Mind Center of Utah Staff. Please be prepared to give payment for services as agreed upon.

• Clear Mind Center of Utah cannot ultimately guarantee that your services will be covered by your insurance. Please note that if a reimbursement is not issued, you are still liable for any outstanding payments owed to Clear Mind Center of Utah.

• We have found that most insurances will communicate inconsistently about its coverages on any single case. Please be aware that this may occur and, if possible, obtain any declarations of coverage in writing or in recorded form.

I acknowledge that I have read and understand the above information.