New Client Intake Form

(If you have not made an appointment yet and are currently interested in knowing more about LENS Therapy and what we do, please call us on 615 331 8762)

Harmonized Brain Centers (Nashville)
Enrollment Information:

Thank you for booking your first appointment.
Please complete this form before your first visit. (if you prefer to fill out this form on paper, please arrive at our offices a few minutes before the time of your first appointment). Any questions please call us on 615 331 8762
Medical Information:
How did you hear about us?

Informed Consent to LENS and Life Coaching-please read carefully.

• Life coaching is not currently a regulated industry in the state of Tennessee. It will be solely the responsibility of the client to determine the effectiveness of the services rendered and the competency of the coach. 2. Life coaching is not psychotherapy or counseling. Life coaching does not address mental disorders as defined by the American Psychiatric Association. Your life coaching sessions are not a substitute for counseling, psychotherapy, mental health care, or substance abuse treatment, Psychotherapy is a healthcare treatment, and its primary focus is to identify, diagnose, and treat nervous and mental disorders. 3. Life coaching assumes the mental health of the client. Life coaching is a collaborative process that is present and future oriented. It is action oriented, solution focused, and encourages change. It involves accountability and commitment to growth through increased competence, commitment, and confidence. 4. As the client, you set the agenda for these sessions and your success will largely depend on your willingness to define goals and try new approaches. You can expect me, as your life coach, to be honest and direct, asking straightforward questions and offering challenging techniques to help you keep moving forward.

• LENS (Low Energy Neurofeedback System) is a non-medical and non-invasive therapy to help the brain regulate and adjust itself to a more normal pattern. While there are no inherent risks associated with the LENS treatment, it is important to be aware that changes with your medication can occur as regulation of the brain takes place. It is your responsibility to be aware of the side effects of your current medications and to discuss change of dosage or amounts with your doctor if you feel that is what is needed.

• Confidentiality is an important element to the coaching process. Your identity and ongoing work will be kept strictly confidential. I will only release information about our work with your written permission or if I am required by court order. The following exemptions apply: 1. There is a broad range of events that are reportable under child protective statutes. Physical or sexual abuse of a child will be reported to Child Protective Services. When the victim of child abuse is over 18, I am not legally required to report it unless I believe there are minors still living with the abuser who may be in danger of being abused. Elder abuse is also required to be reported to the appropriate authorities. 2. If you are at imminent risk of yourself or someone else or make threats of imminent violence against another person, I will take appropriate action.

• Fees, Payment Schedule & Cancellation policy

◦ 1) Payment is due at the start of each session. Note that there is no insurance coverage for these sessions.

◦ 2) Please call within 24 hours of your scheduled appointment to cancel or reschedule.

◦ 3) If an appointment is cancelled in less than 24 hours of the scheduled appointment, or

if you are a “no-show” to the appointment, a $50 cancellation fee will be charged at

your next visit.

◦ 4) Of course, we understand that circumstances beyond our control (sickness, vehicle malfunctions, other emergencies) do occur; and

we will address these on a case by case basis with fairness.

◦ 5) We now have waiting lists of several weeks for those wanting to see us. It is in fairness to them and to our practitioners that we are

implementing this practice. Thank you in advance for your cooperation and understanding


Acknowledgment and Release of Liability:

By Signing this disclosure and consent statement, I acknowledge that I understand the above information. I agree to hold Harmonized Brain Centers (the dba of Five Dog Enterprises inc) and my life coach from all liabilities and claims which may arise as a result of my participation in LENS and life coaching.

Information is not to be released to anyone without my consent

The release of information will be in effect until I terminate it in writing.

Thank you for taking the time to provide this information. We look forward to meeting you and discussing how we can help.

If you have any questions, please do call on 615 331 8762. For more information about what we do and LENS Neurofeedback therapy, please visit our website: www.harmonizedbraincenterstn.com