Informed Consent

A Restored Mind, PLLC

Welcome to A Restored Mind, PLLC! This informed consent explains the nature of qEEG Brain Mapping, Neurofeedback, relaxation and stress-reduction interventions, including their potential benefits and risks. Your participation in these services is voluntary.

At A Restored Mind, PLLC, we value a collaborative approach to care. We encourage you to communicate openly with your Neurofeedback provider, ask questions, and actively participate in decisions regarding your care while understanding your rights and responsibilities as a client.

qEEG Brain Mapping A qEEG Brain Map is completed to help develop an individualized neurofeedback service plan. The mapping process involves placing a cap with 19 sensors on the scalp. Each sensor site is cleansed, and conductive gel is applied to record brainwave activity. The brain mapping process, including preparation, recording, and review of the results, typically takes about one hour.

qEEG Benefits Neurofeedback is not intended to diagnose, treat, cure, or prevent any medical or mental health condition. Neurofeedback is an educational and self-regulation service designed to improve operant conditioning and wellness. Clients should continue working with their healthcare providers regarding medical and behavioral health needs.

qEEG Side Effects/Risks The qEEG cap may cause a mild headache and/or skin irritation.

Forensic Services Neurofeedback and qEEG Brain Mapping at A Restored Mind, PLLC are not medical procedures and are not performed to diagnose or treat medical, neurological, or mental health conditions. Services are provided solely to support self-regulation and are not intended for forensic or legal purposes.

A Restored Mind, PLLC does not provide forensic evaluations, medical diagnoses, disability or workers' compensation documentation, expert testimony, or depositions. Clients seeking these services should consult an appropriately licensed medical provider or forensic neuropsychologist.

By signing this consent, you acknowledge that you will not request these services from A Restored Mind, PLLC. If the practitioner is subpoenaed or otherwise legally required to participate in a legal proceeding, a $500 retainer plus $150 per hour will be charged for preparation, travel, court appearance, testimony, and related professional time.

Equipment/Software qEEG measurements will involve the use of New Mind software. Software products and New Mind equipment is FDA registered and maintain client confidentiality standards.

Neurofeedback Sessions Neurofeedback is a non-invasive, drug-free wellness service that supports the brain's ability to self-regulate. It is not intended to diagnose, treat, cure, or prevent any medical, mental health, or physical condition and is not a substitute for medical or mental health care.

During each session, sensors are placed on the scalp and earlobes using a conductive paste to monitor brainwave activity. The sensors do not deliver electrical stimulation; they only record brainwave activity so the system can provide visual and auditory feedback. Photic stimulation will not be used when contraindicated.

Neurofeedback is a training process, and results vary based on the individual. No specific outcome or improvement can be guaranteed. Progress may be influenced by factors such as health status, medications, sleep, stress, nutrition, and consistency with training. Sessions typically last 30–45 minutes, with the neurofeedback portion lasting approximately 15–30 minutes. The number of sessions varies based on individual needs and goals. Clients may discontinue services at any time.

Neurofeedback benefits and risks/side-effects As with any intervention, neurofeedback has potential benefits and risks. Neurofeedback is considered a low-risk, non-invasive form of biofeedback when administered appropriately. Temporary side effects may include headache, fatigue, or emotional changes, which typically resolve within 24–48 hours. Clients should notify their Neurofeedback provider of any side effects so training can be adjusted if needed.

Medication Management Please inform A Restored Mind, PLLC of any changes to your medications during neurofeedback training. Because medications can influence neurofeedback outcomes, starting or changing medications during treatment may make it difficult to determine each intervention's effects.

If you take medications for behavioral health conditions, you should notify your prescribing provider that you are participating in neurofeedback so your treatment can be appropriately monitored. Please do not start, stop, or change any medication without the guidance of your prescribing provider. A Restored Mind, PLLC does not prescribe or manage medications or supplements.

Choosing the Right Intervention The interventions described above are voluntary, not mandatory. You will not be pressured to participate in Neurofeedback services. You may withdraw from/stop receiving neurofeedback services at anytime without consequence.

Financial Policy A Restored Mind does not accept health insurance and is not a Medicaid/Medicare provider. Please be prepared to pay at the time services are rendered. Initial and repeat qEEG brain maps are $350 for traditional and coherence neurofeedback services. Each in-office neurofeedback session is $85 per session. Each home kit neurofeedback session is $65 per session and a weekly $45 technology fee. Please be aware that you are ultimately responsible for the timely payment for your account. If any previous sessions have not been paid for, client will not be allowed to attend next appointment. We reserve the right to charge for appointments canceled or broken without 24-hour advanced notice. Our fee for broken appointments (those without 24-hour notice) is $50 per session. For your convenience, we accept cash, checks, credit cards, HSA or FSA accounts.

Electronic Communication A Restored Mind, PLLC uses HIPAA-compliant technology for qEEG Brain Mapping, neurofeedback, and client records. Text messaging may be used for scheduling and general communication, but is not HIPAA compliant and should not be used to share personal health information.  By communicating electronically with A Restored Mind, PLLC, you acknowledge and accept the inherent privacy and security risks associated with electronic communication.

Client Rights

• Receive respectful, compassionate, and professional care in a safe environment free from abuse, neglect, discrimination, or mistreatment.
• Ask questions, participate in service decisions, establish goals, and refuse or discontinue services at any time.
• Receive information about qEEG Brain Mapping and Neurofeedback procedures, including the opportunity to discuss concerns or decline specific techniques.
• Have your health information protected in accordance with HIPAA and applicable state and federal laws. Confidentiality may be limited when disclosure is required by law, including situations involving abuse, neglect, safety concerns, court orders, or other mandatory reporting requirements.

Client Responsibilities

• Provide complete and accurate personal, medical, and medication information, and promptly report any changes.
• Notify your prescribing provider that you are participating in neurofeedback and consult them before starting, stopping, or changing any medications.
• Provide legal custody or guardianship documentation, when applicable, before services are provided to a minor.
• Attend appointments as scheduled. Appointments canceled with less than 24 hours' notice are subject to a $50 cancellation fee.
• Actively participate in your care by communicating questions, concerns, and progress toward your goals.
• Notify A Restored Mind, PLLC if you choose to discontinue services.

We are grateful you have chosen to seek services at A Restored Mind, PLLC. We are so excited to be on this wellness journey with you! If you have any questions or concerns, please discuss them with your neurofeedback provider.

Acknowledgment and Consent I acknowledge that I have read and understand this Informed Consent. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction. I understand the nature, potential benefits, and potential risks of the services provided by A Restored Mind, PLLC, and I voluntarily consent to participate in qEEG Brain Mapping, Neurofeedback, and related services.