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PATIENT IDENTIFICATION. Although all the information you give here is secure through SSL encryption, please be aware that we cannot GUARANTEE privacy. If you prefer, you may complete this form on paper and either mail or fax it to us for security purposes. By completing this form on-line and submitting it upon completion, you are acknowledging and accepting the risk that this information may not be secure.

Please identify the patient who will be receiving neurofeedback.

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Do you plan to be seen for neurofeedback in our Providence, RI office or in our Cambridge, MA office?

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Who is completing the suvey? Please give your relationship to the patient:

Please describe your goals for neurofeedback training. What would you regard as a successful outcome? What changes do you want to achieve? Be as specific and detailed as possible. How, when, and where will you be able to observe these changes?

Please list the goal based on the general or overall function involved (eg, reduce hyperactivity), the specific behavior that shows that function (eg, unable to sit through family dinner), and the current status of that behavior (eg, never able to do this). Feel free to list more than one behavior as an illustration of a general function. Here is another example:

Function: Reduce anxiety
Behavior: Being in a room alone
Status: 90% of the time he insists that someone be with him

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Goal #1

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Goal #2

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Goal #3

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Goal #4

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Is there anything else you wish to tell us about your goals for neurofeedback training?

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FOR NDC STAFF ONLY. Any additional information:

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