Please complete and bring the required forms to your initial appointment, along with your insurance card and any other forms listed below that your provider has requested. Other relevant history or testing is also requested.

Required Forms: Please complete and bring to first appointment

Intake Form

Client History Form

Client Terms of Agreement

Email Consent Form

Authorization for the Release of Protected Health Information

Notice of Privacy Practices – To Read Only.  Not to bring in. 

Print, Read and Sign Hippa Privacy Documentation Form to Bring to First Appointment
The provided HIPPA information does not need to be printed out. Please read this form prior to your first appointment, then print out and sign the HIPPA acknowledgment, form before bringing it to your initial appointment.

Forms You May Have Been Requested to Bring to Initial Session:

Neurofeedback Consent Form

Nexalin Consent Form

Release to Communicate with Other Providers

Neurotherapy Session Reporting Forms

Brief Neurotherapy Tracking Sheet

Narrative NF Tracking Sheet

NT Tracking For Over Active Youth

Please complete and bring the required forms to your initial appointment, along with your insurance card and any other forms listed below that your Wellspring provider has requested. Other relevant history or testing is also requested.

Required Forms: Please complete and bring to first appointment

Client History Form

Client Terms of Agreement

Read and Sign Hippa Privacy Documentation Form to Bring to First Appointment
The provided HIPPA information does not need to be printed out. Please read this form prior to your first appointment, then print out and sign the HIPPA acknowledgment, form before bringing it to your initial appointment.

Forms You May Have Been Requested to Bring to Initial Session:

Nexalin Consent Form

Release to Communicate with Other Providers