Biofeedback Consent Form

Thank you for taking the time to fill out this form before your session.


Informed consent for Biofeedback training

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 client 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. A remote session can also be performed using quantum physics, in which case no equipment will be connected to the client.

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.

My goal is to help you find the proper balance of stress levels in yourself, and possibly retrain your body to respond appropriately to stressors by applying Biofeedback techniques.

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.



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.



Your signature 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.