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:
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

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

1) LENS Neurofeedback and Life coaching are 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) LENS Neurofeedback and Life coaching are 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. 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 your life coach, to be honest and direct, asking straightforward questions and offering challenging techniques to help you keep moving forward.
4) 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 known 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.
5) Confidentiality is an important element to 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 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, we are not legally required to report it unless we 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, we will take appropriate action.
6) The therapists at Harmonized Brain Centers are not psychologists, psychiatrists or professional mental health specialists. They are licensed LENS Neurofeedback practitioners and Life Coaches.
6a) Harmonized Brain Centers reserves the right to refuse the use of LENS Neurofeedback on any client, for any reason without explanation. Furthermore Harmonized Brain Centers reserves the right to discontinue LENS Neurofeedback therapy at any time without explanation. No refunds will be given for any previous sessions. Acknowledgment and Release of Liability:
7) In consideration of the risk of injury that exists while participating in LENS Neurofeedback (hereinafter the "Activity"); and in consideration of my desire to participate in said Activity and being given the right to participate in same;
I hereby for myself, my heirs, executors, administrators, assigns, or personal representatives (hereinafter collectively, "Releasor," "I" or "me", which terms shall also include Releasor's parents or guardian if Releasor is under 18 years of age), knowingly and voluntarily enter into this WAIVER AND RELEASE OF LIABILITY and hereby waive any and all rights, claims or causes of action of any kind arising out of my participation in the Activity; and I hereby, release and forever discharge Five Dog Enterprises Inc, dba Harmonized Brain Centers located at offices in Nashville, TN and surroundings areas, including, but not limited to Murfreesboro, Tennessee, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns (collectively "Releasees"), from any physical or psychological injury that I may suffer as a direct result of my participation in the aforementioned Activity.
8) I am voluntarily participating in the aforementioned Activity, and I am participating in the activity entirely at my own risk. I'm aware of the risks associated with participating in this Activity, which may include but are not limited to physical or psychological injury, pain, suffering, illness, temporary, or permanent disability, including paralysis, or numbness, economic or emotional loss and death. I understand that these injuries or outcomes may arise from my own, or others, negligence and conditions related to other therapies or drugs. Nonetheless, I assume all related rest, both known and unknown to me of my participation in this activity.
9) I further agree to indemnify, defend and hold harmless the Releasees 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.
10) I further acknowledge that the Releasee’s are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasee’s. In the event that I should require medical care or treatment, I authorize Five Dog Enterprises inc dba Harmonized Brain Centers to provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs involved and agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.
11) I further acknowledge that this Activity may involve a test of a person's physical and mental limits and may carry with it the potential for death, serious injury, and property loss. I agree not to participate in the Activity unless I am medically able, and I agree to abide by the decision of the Five Dog Enterprises inc dba Harmonized Brain Centers official or agent, regarding my approval to participate in the Activity.
12) I hereby acknowledge that I have carefully read this waiver and release and fully understand that it is a release of liability. I expressly agree to release and discharge Five Dog Enterprises, Inc., DBA, as Harmonized Brain Centers, and all of its affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successes, and assigns from any and all claims or causes of action. I agree to voluntarily give up or waive any right to die otherwise have to bring a legal action against Harmonize Brain Centers for personal injury or property damage.
13) To the extent that statute or case law does not prohibit releases for ordinary negligence, this release is also for such negligence on the part of Five Dog Enterprises inc dba Harmonized Brain Centers its agents, and employees.
14) 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.
14a) 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.
15) 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. In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and effect. If a court should find that any provision of this agreement to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed, and enforced as so limited.
16) 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.
17) 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)
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. In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and effect. If a court should find that any provision of this agreement to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed, and enforced as so limited.
18) 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