HEALTH + WELLNESS

QUANTUM BIOFEEDBACK SESSION

QUANTUM is the smallest amount of a physical quantity that can exist independently, especially a discrete quantity of electromagnetic radiation. This amount of energy is regarded as a unit. Quantum Biofeedback is a non-invasive sophisticated technology that energetically scans the strength of your reactions to thousands of electronic signatures of a broad array of items. It retrains your body and mind to a better "reactivity" in a finely tuned way and re-educates muscles for stress reduction. Excess stress is a leading precursor to many diseases and conditions.

STRESS MANAGEMENT

Stress Reduction

PAIN MANAGEMENT

MUSCLE RE-EDUCATION

New Client Intake Form

RP CREATIVE CONSULTING PO Box 192, Penngrove CA 94951 707.206.1200 www.rpcreativeconsulting.com ryan@rpcreativeconsulting.com INFORMED CONSENT FOR BIOFEEDBACK TRAINING MY BACKGROUND Paragraph written in the first person describing your background, including education, training, certifications/licenses, the services that you provide and the goals that you want your clients to achieve. Unless you are licensed to practice as such, you should include the following statement: I am not licensed as a physician, psychologist or chiropractor, and I cannot and will not diagnose, treat, cure, mitigate or prevent any medical or psychological disease, disorder or condition. BIOFEEDBACK Biofeedback is a complementary and alternative medicine technique which enables an individual to learn to change some physiological activities for the purpose of improving health. With biofeedback, the subject is connected to the biofeedback device with sensors to measure and receive information (feedback) about the body (bio). The biofeedback sensors use mild electrical impulses that measure skin temperature known as Electro Dermal Response (EDR), which teaches the individual to make subtle bodily changes, such as relaxing certain muscles, to achieve desired results, such as reducing pain. Biofeedback is often used as a relaxation technique. The instrument utilized in the training sessions is called the Eductor biofeedback system, which requires that the client connect to the system with a head band, ankle and wrist straps to measure EDR. The scope of my practice through the use of this biofeedback system includes stress reduction training programs for relaxation training, pain management, muscle re-education and brainwave training. Although this training is expected to produce beneficial results, such results cannot be guaranteed. Biofeedback training is a complement, not a substitute, for medical or psychological treatment, and any ongoing treatment should not be discontinued without advice of your treating physician. OTHER MODALITIES (if applicable) CONFIDENTIALITY Client information will be kept in confidence and will not be disclosed to anyone outside of this office without your written consent, unless as is required by law. ARBITRATION PROVISION Arbitration sets forth an agreement to forgo court action to settle disputes that arise between client and practitioner. Local organizations may provide arbitration services which may be subscribed to handle such matters. CONSENT Typing your full name and checking the the box below indicates that you have read and understood the information in this document and that you consent to biofeedback training under the provisions stated. If you do not understand or consent to anything stated in this document, it is your responsibility to request and receive clarification before signing.

Clients Full Name

First Name

Last Name

I agree and understand

Date

YYYY

Parent or Guardians Full Name

First Name

Last Name

Date

YYYY

SOC

Please answer each question below to the best of your ability. If you are unsure enter 0.

Number of organs removed

Number of synthetic drugs used

Amount of times you smoke per day

(number of cigarettes, cigars, etc)

Number of steroid type drugs used in the past year

Number of Street Drugs used/month

Number of known allergies

Number of unresolved mental factors

I am responsible for my body

0 being minimum, 10 being maximum

Amount of fat in diet as percent /10

includes processed foods

Personal Stress 0-10

10 being max

Number of sugar type products per day

includes soft drinks, ice cream, etc

Number of work out sessions per week

20 mins or more (not work)

Number of alcoholic drinks per day on average

Number of cups of coffee or tea per day

or any caffeine products

Number of expreme toxic exposures per year

radiation, insecticide, chemicals

Number of major injuries in past

Number of major infections

How much water do you drink per day

(in ounces)

How much natural juices do you drink per day

in ounces

How many kilos overweight do you consider yourself

2.2 lbs = 1kg

Are you currently experiencing any health issues?

Anything else we should know about so we can best address your specific needs

BIOFEEDBACK