First Visit Form
AMSTERDAM
Please read through the informed consent and complete all the relevant information.
INFORMED CONSENT FOR NEUROFEEDBACK/BRAIN-BASED COACHING
Dr. Charlene Heyns-Nell is a Neurofeedback Practitioner (New Mind) an has extensive experience and expertise with the brain and brain related behaviours.
WHAT IS NEUROFEEDBACK?
EEG neurofeedback, or brain wave biofeedback is a non-medical, but science-based, general training that takes advantage of the body’s natural ability to self-regulate and seek balance. Non-invasive sensors or “electrodes” are connected to specific sites on the surface of the head. The sensors pick up brain waves and display them on a computer screen. The computer assists the brain in recognising normal brainwave patterns and produces either visual or auditory feedback. When the brain is producing the appropriate balance of waves, it will receive positive feedback. When the brain is not producing the correct balance of waves, it will receive negative feedback. The specific type of feedback you will be receiving is dependent upon the protocol. The protocol is determined by the diagnosis which will be discussed in session.
The feedback allows the brain to learn to produce balanced, efficient brainwave patterns more frequently. In Dr. Charlene’s observation of this kind of training it has proved to increase the strength and flexibility of the brain, thereby reducing emotional and physical difficulties, and supporting healthy brain/body functioning. Additionally, as the EEG dynamics stabilise, many improvements in mood, sleep, concentration, and behaviour can be seen by her clients. Dr. Charlene cannot, however, guarantee what the exact changes will be, or if they will occur at all. Most, but not all, see extensive improvements.
THE STATUS OF NEUROFEEDBACK
While neurofeedback has been approved by the Food and Drug Administration (FDA) for stress reduction, the use of this device for treatment of medical conditions is still considered experimental. There is a plethora of research available regarding neurofeedback and its effectiveness with a variety of disorders including, but not limited to, uncontrolled epilepsy, Attention Deficit Hyperactive Disorder (ADHD), anxiety, alcoholism, Post traumatic Stress Disorder (PTSD), mild head injuries, learning disabilities, stroke, depression, fibromyalgia, autism, insomnia, tinnitus, headaches, problems with physical balance, as well as peak performance (Hammond, 2006).
Neurofeedback often produces very beneficial and lasting changes; however, there are cases where damage to the brain is such that remediation may not be possible, or there may only be partial improvement. Partial improvement is more often the case. Dr. Charlene generally expects a positive response within the first 10-15 sessions. If no improvement is achieved in that time, she might recommend suspending training. In most of the cases where there is improvement in function, it then becomes the Client’s responsibility to monitor progress, and to continue training if required or perceived to be of benefit. To that end, you will be asked to complete frequent evaluations that will measure ongoing treatment progress. Your ability to be as consistent as possible with these evaluations is required. Consistency is necessary for Dr. Charlene to obtain accurate information about how the training is affecting you. This will be instrumental in helping to make the best decisions about the course of training as it progresses. While there are often improvements in the first few sessions, neurofeedback training usually requires at least 20, and most commonly 20-40 sessions with a small number of follow-up reinforcement sessions for permanent change to take place.
LIMITATIONS OF TRAINING AND POTENTIAL RISK
It is important to understand that a QEEG (quantitative electroencephalography scan) is NOT the same as a “clinical EEG” which is used in medical diagnosis to evaluate epilepsy or to determine if there is serious brain pathology, such as a tumour. The neurofeedback computer records the way a client’s brain waves function. It is not designed and is not used to diagnose medical conditions. Neurofeedback is a non-invasive, safe procedure, and no electrical current is put into the brain. To obtain good electrode connections, it is necessary to clean small areas of the scalp with rubbing alcohol and apply paste to attach the electrodes. This might cause slight discomfort in these areas for a short period of time. In terms of the neurofeedback training itself, rarely have significant side effects been reported. Occasionally, someone may feel tired, spacey, anxious, experience a headache, have difficulty falling asleep, or feel agitated or irritable. Many of these feelings pass within a brief time following the training session.
If your symptoms do not dissipate, you should report this at your next session so that the training protocol can be modified. Unwanted effects usually seem to be related to the instabilities in your nervous system that brought you to training in the first place. The goal is to keep you as comfortable as possible, although this does not affect any effectiveness of training (e.g. feeling sore after going to the gym does not mean you are not benefitting from the workout). Some clients may feel an increased need to sleep during the first few weeks of training. This may be due to a variety of factors, but in general, is considered normal and a sign that the brain is renormalising between sessions. Please make allowances for the increased need to sleep, and sleep as your body requires. Please be aware that training can be incredibly relaxing. Please exercise usual caution and good judgment regarding your ability to drive afterwards.
MEDICATIONS AND CONSULTATION WITH YOUR PHYSICIAN
You should also be aware of the relationship between neurofeedback and medications. Sometimes more neurofeedback sessions are needed if a client is on medication, and neurofeedback may change the dosage requirements for some medications. Therefore, it is very important that the physician monitoring your medication is made aware that you may require a dosage change. You will be asked to fill out a release, so Dr. Charlene may communicate with your prescribing physician regarding your neurofeedback participation, and the need to monitor you for overmedication. If you are experiencing unusual symptoms, you should discuss them with your physician. Do not stop or alter your medications without consulting with your physician. Neurofeedback is not a substitute for effective standard medical treatment. Neurofeedback training can substantially affect your glucose level as your brain works very hard when you train. Please have a meal or snack with protein before coming to appointments and let us know if you are diabetic or hypoglycemic. In addition, it is very important for Dr. Charlene to know if you have or have had epileptic seizures.
CONFIDENTIALITY
Information shared in sessions is kept confidential and will not be disclosed except in cases of: 1) Situations in which you are deemed to be a danger to yourself or others (i.e. threats of homicide or suicide); 2) Situations in which children are endangered or have been abused. 3) Information from training sessions that will be shared with professional colleagues. If you see Dr. Charlene in the community, she will not approach you; however, if you would like to approach her, that is completely acceptable and welcome. Dr. Charlene takes confidentiality seriously, and by adopting a “you first” policy, she gives you the option to acknowledge your professional relationship with her on your own accord.
When participating in EEG Neurofeedback training, you are granting Dr. Charlene permission to share information regarding your medical history, training sessions, and training results with colleagues within in the field of neurofeedback for the purpose of case consultation and treatment enhancement. Names or other primary identification information will not be shared. In participating in this treatment, you understand that a commitment of twice a week is expected to ensure optimal treatment effects.
Additional information may be shared with related parties, at your request, with a signed Release of Information.
CANCELLATION POLICY
By taking part in this programme you have been given the opportunity to improve your mental health through neurofeedback training at a fraction of what neurofeedback sessions usually cost. If a session needs to be cancelled, for any reason, you may do so once during the programme. If you cancel within 24 hours or do not show up for the appointment, you are not able to continue with the programme. If you are more than 15 minutes late for your appointment, your appointment will be cancelled. This counts as as a cancelled session. None of the above circumstances can result in a refund. If Dr. Charlene is late, you will still receive your full session.
FINANCIAL POLICY
All payments are to be made before sessions. A non-refundable fee that covers some of the cost of the training is charged.
ADDITIONAL INFORMATION
When you arrive for your appointment, please use the restroom BEFORE you come into the office. Once the electrodes have been placed and training has begun, you will not be able to use the restroom until the training has been completed. The duration of training is approximately approximately 30-45 minutes. Parents are welcome to sit in on a few sessions initially to ease your child’s anxiety and/or to gain a better understanding of the training experience and ask any questions that may arise. After the first few sessions, parents will be invited into the session for the first few minutes to discuss any changes your child is experiencing. Even though neurofeedback is not like traditional therapy, Dr. Charlene requests that her office be viewed as a therapeutic space. Here you or your child can express feelings of discomfort or suicidal/homicidal ideations, so that she may help you obtain the appropriate services if necessary. Once a session has started, it will not be stopped unless the patient or parent requires a break. Dr. Charlene respectfully requests that parents, or friends and family, do not disrupt the session except in the case of an emergency. If the client starts to fall asleep during treatment, Dr. Charlene will give three warnings to wake up. If three warnings are given and the client continues to sleep, the session will be an expensive cat nap. So, please ensure you obtain an adequate amount of sleep before each session. Dr. Charlene’s neurofeedback process takes into consideration the person as whole. She may provide you with specific therapeutic interventions designed to further improve treatment outcomes. While neurofeedback is not traditional therapy, there may be times when you may require additional support. Dr. Charlene may recommend therapy to address areas that are not improved by neurofeedback.
VOLUNTARY PARTICIPATION AND CONSENT TO NEUROFEEDBACK/BRAIN-BASED COACHING
By submitting this form, I have carefully reviewed the informed consent statement. I do voluntarily, knowingly, and willingly give my consent to the use of EEG neurofeedback and/or Brain-based Coaching.
PERSONAL INFORMATION FOR FIRST VISIT
** If the client is under the age of 18, the parent or legal guardian must complete all the relevant information on behalf of the client. The e-mail and contact number should be either the parent or legal guardian's. Parent(s) or legal guardians must answer the personal questions about stroke, death in family, divorce, relocation, job change, family chronic illness. This is important information and directly affects the client.