Informed Consent for Low Energy Neurofeedback System (LENS)

Denise Ibrahim, of NW Skyline Counseling & Biofeedback, has informed me that she sometimes uses Low Energy Neurofeedback System (LENS) as a helpful technique in psychological treatment for a variety of conditions, such as traumatic brain injury, stroke rehabilitation, fibromyalgia, depression and other mood and anxiety disorders, hyperactivity, explosiveness/anger and learning disorders.

I understand that LENS is a method of teaching someone to produce brain-wave patterns that can enhance the brain’s ability to adapt to a task.

Although no significant negative side effects have been observed so far, we will discuss all possible side effects of LENS treatments.  My understanding of them will help me to work with Denise Ibrahim to provide successful treatment.  If I experience any side effects, I will immediately inform Denise Ibrahim so she can work closely with me to adjust the dosage.

I understand that I must be medically stable to engage in this treatment.  I will immediately inform Denise Ibrahim if I have any changes in medication, especially any changes that could affect my medical stability.  I will consult my physician immediately if Denise Ibrahim advises me to do so.

I understand that I may discontinue treatment at any time for any reason.  Should I wish to discontinue treatment, I will inform Denise Ibrahim who will provide copies of any records for another therapist.

I understand that success with the LENS is best predicted with a complete evaluation and the development of a treatment plan.  The evaluation allows us to predict which symptoms will respond, and which may respond first.  And, as with any treatment, there can be no guarantee of success in any particular instance.  Before I give my consent to be treated, we want you to ask as many questions as are necessary for you to understand this process.  Please continue to express your questions, observations, and concerns at any time during the treatment process.

LENS does not involve the practice of medicine.  Denise Ibrahim and I have discussed the advantages and disadvantages of LENS, and alternatives to this therapy.  The treatments are non-diagnostic, and are complementary to the healing arts services that are licensed by the State of Washington.  If I have any complaints that cannot be resolved between NW Skyline and me, I may contact the Washington State Department of Health, P.O. Box 1099, Olympia, WA 98507

For more information about LENS, refer to http://www.ochslabs.com. For more information about body lens/ photonics, please visit http://www.photonicstimulator.com   _______________________________________________________                            ___________________

Client Signature                                                                                                                Date

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Parent or Guardian Signature                                                                                         Date  

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Denise Ibrahim, MS                                                                                                          Date