New Client Intake Form

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 you are a “no-show” to the appointment, a $75 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. Harmonized Brain Centers (Nashville and Murfreesboro)

ENROLMENT INFORMATION AND CONSENT FOR LIFE COACHING AND LENS NEUROFEEDBACK THERAPY

1) 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. 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 service, and its primary focus is to identify, diagnose and treat nervous and mental disorders. 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. As the client, you set the agenda for these sessions and your success will largely depend upon your willingness to define goals and try new approaches. You can expect us, as your life coach, to be honest and direct, asking straightforward questions and offering challenging techniques to help you keep moving forward.
2) LENS (Low Energy Neurofeedback System) is a non-medical, non-invasive therapy to help the brain regulate and adjust itself to a more normal pattern. While there are no inherent risks associated with LENS treatment, it is important to be aware that changes with your medications 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 changes of dosage or amounts with your doctor if you feel that it is needed.
2a) The staff at Five Dog Enterprises Inc dba Harmonized Brain Centers TN are not psychologists, psychiatrists or professional mental health specialists. They are licensed LENS Neurofeedback practitioners.
3) Harmonized Brain Centers TN reserves the right to refuse the use of LENS Neurofeedback on any client, for any reason without explanation. Furthermore, Harmonized Brain Centers TN reserves the right to discontinue LENS Neurofeedback therapy at any time without explanation. No refunds will be given for any previous sessions.
4) I further agree to indemnify, defend and hold harmless the Five Dog Enterprises (dba Harmonized Brain Centers of Nashville and Murfreesboro against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs.
5) I agree that this Release shall be governed for all purposes by Tennessee law, without regard to any conflict of law principles. This Release supersedes any and all previous oral or written promises or other agreements. In the event that any damage to equipment or facilities occurs as a result of my or my family's or my agent's willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any such actions of neglect or recklessness.
6) This waiver and release of liability shall remain in effect for the duration of my participation in the activity during this initial, and all subsequent events of participation and 180 days thereafter.
7) This agreement was entered into at arm's-length, without duress or coercion, and is to be interpreted as an agreement between two parties of equal bargaining strength. Both Participant, (please fill in your name in the box below)

and Five Dog Enterprises Inc dba HARMONIZED BRAIN CENTERS, agree that this agreement is clear and unambiguous as to its terms, and that no other evidence shall be used or admitted to alter or explain the terms of this agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into.
8. Confidentiality is an important element of the coaching process. Your identity and ongoing work will be kept strictly confidential. We will only release information about our work with your written permission, or if we are required to by court order. The following exceptions will apply: There are a broad range of events that are reportable under child protection statutes. Physical or sexual abuse of a child will be reported to the Child Protective Services. When the victim of child abuse is over age 18, we are not legally mandated to report it unless we believe that 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.
If you are at imminent risk to yourself or someone else or make threats of imminent violence against another person, we will take appropriate action.
9. Fees, Payment Schedule and Services. The payment is due at each session. Note that we do not take insurance or file for insurance for you. We can take HSA cards and we can give you a superbill for you to give your insurance company.
10. We request that you provide at least a 24-hour notice if you need to cancel or reschedule your appointment. Failure to do so will result in a charge of $75. By signing this disclosure and consent statement, I acknowledge that I understand the above information. I agree to hold harmless Harmonized Brain Centers of Tennessee and my life coach from all liability and claims which may arise as a result of my participation in life coaching or LENS Neurofeedback.
11. I the undersigned participant affirm that I am of the age of 18 years or older and that I am freely signing this agreement. I certify that I've read this agreement that I fully understand its content and that this release cannot be modified orally. I'm aware that this is a release of liability and a contract and that I'm signing it of my own free will.
12. PARENT / GUARDIAN WAIVER FOR MINORS (if applicable) In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows: I HEREBY CERTIFY that I am the parent or guardian of: (Put in N/A if not applicable).

13. I the undersigned participant affirm that I am of the age of 18 years or older and that I am freely signing this agreement. I certify that I've read this agreement that I fully understand its content and that this release cannot be modified orally. I'm aware that this is a release of liability and a contract and that I'm signing it of my own free will. Harmonized Brain Centers (Nashville) Enrollment Information:

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.