Robert E. Longo, MRC, LPC, NCC Serendipity Healing Arts Board Certified in Neurofeedback CONSENT FOR TREATMENT

Transcription

1 Robert E. Longo, MRC, LPC, NCC Serendipity Healing Arts Board Certified in Neurofeedback CONSENT FOR TREATMENT The purpose of this form is to obtain your voluntary consent to participate in one or more methods of assessment and/or treatment, and to disclose potential risks associated with this type of therapy/treatment. This informed consent covers a variety of procedures and treatments. The treatment provider has checked the items in this document that pertain to your assessment and treatment. It is important that the patient read this document closely and then check, initial, and sign for all procedures/treatments that the patient will be receiving. Please note that all of the procedures described involve touch (i.e., placing electrodes on the scalp, placing sensors on the hands, skin, or around the waist). If the patient is uncomfortable with being touched by another person, the patient should advise the treating professional immediately. QEEG Brain Mapping/Assessment Electroencephalography (e-lec-tro-enceph-a-lo-graphy ~ EEG) is a neurological diagnostic procedure that records the changes in electrical potentials (brainwaves) in various parts of the brain. By recording the electrical activity of the brain from the scalp, EEG images the brain by taking measures with both eyes closed and eyes opened; and may also be done while the patient is performing a cognitive task. This allows for detection of the location and magnitude of brain activity involved in the various types of cognitive functions. Images are acquired by placing a cap with electrodes on the head or by using individual electrodes to monitor the amount of electrical activity at different points on the scalp. Quantitative Electroencephalography (QEEG) is the measurement, using digital technology, of electrical patterns at the surface of the scalp which primarily reflect cortical activity or "brainwaves". A multi-electrode recording of brain wave activity is recorded and converted into numbers by a computer. These numbers are then statistically analyzed and are converted into a color map of brain functioning. Consent for Treatment ~ Page 1

2 The QEEG mapping system used for this mapping is the New Mind Magnitude Analysis System. The Magnitude Analysis System provides a reference database system that provides simple output indicating whether EEG is high or low in the various dimensions of analysis. QEEG consists of placing a cap with twenty electrodes/sensors on the patient s head, and ear clips on each ear lobe. Each site will first be cleansed and electrode paste/gel will be placed under each sensor to insure proper conductivity to read the patient s brainwaves. The recording is done while the patient is in a reclining chair. The patient is asked to relax with eyes closed and a second set of measures is taken with eyes opened. Preparation takes approximately minutes and the actual EEG recordings take about 15 minutes. QEEG measures will involve the use of the BrainMaster software and hardware including a BrainMaster Atlantis I 4X4 Unit and a BrainMaster Mini-Q II unit as well as an Elctro-Cap with electrodes, and Electrogel and/or 10/20 Electrode Paste. Areas where sensors/electrodes may be placed will be prepped with NuPrep and/or an alcohol prep pad. NOTE: In order to participate in neurofeedback, patients are required to have a QEEG. In other instances, to help verify a disorder, we may recommend that the patient have a QEEG. The benefits of QEEG include but are not limited to assessing overall brain function that includes magnitude (power) connectivity (brain functioning) and asymmetry (the balance of certain brain waves). In addition the QEEG will produce an analysis of cognitive functioning, an emotional analysis, a list of supplements that may be deficient and a list of metabolic categories. QEEG helps assess the patient s need for specialized treatment. Generally, if the patient has problems with stress, anxiety, insomnia, and/or depression they will benefit from one or more of the treatments listed below. For example, if the patient has elevated vital signs, i.e., high blood pressure, elevated heart rate; the patient may benefit from Biofeedback. There are generally no risks involved with QEEG. In some cases patients may feel anxious about having the procedure done. There are no known side effects. QEEG provides an analysis of brain functioning. Alternative methods of determining brain functioning include but are not limited to psychological and neurological testing, Medical EEG, MRI, fmri, brain scans including CAT and SPECT. Consent for Treatment ~ Page 2

3 The risks associated with not having a QEEG are that the individual may not have a complete understanding of possible disorders. PLEASE NOTE: QEEG cannot be used for diagnostic purposes,; however, it may be used for differential diagnosis. Biofeedback / Peripheral Biofeedback Biofeedback is a non-invasive form of treatment. Sensors or electrodes are attached to the body and these sensors provide a variety of readings feedback which is displayed on the equipment for the patient to see. The signals typically measure what are thought of as involuntary body functions (see paragraph below) and/or brainwave function. With this information, patients can learn to make changes so subtle that at first they cannot be consciously perceived. With practice, however, the new responses and behaviors can help to bring relief and improvement to a variety of disorders. Biofeedback is a term that includes/covers a variety of treatment modalities including peripheral biofeedback (i.e., heart rate, blood pressure, skin response, breathing rate, muscle tension, body temperature), and EEG Biofeedback or neurofeedback (brain wave biofeedback). The application of computer software and hardware, and homework exercises (i.e., relaxation and meditation techniques) are used to help the patient relax and manage/treat anxiety, stress, frustration, anger, depression, insomnia, pain, and other mental health and physical health disorders. Biofeedback is continuously subjected to rigorous study and evaluation by the international medical and mental health communities. Biofeedback is an effective treatment for a variety of syndromes involving the management of anxiety, depression, ADD, ADHD, and/or post traumatic stress disorder (PTSD), and in many cases can be a required and/or the preferred therapeutic method to help the patient succeed in their overall treatment. Peripheral Biofeedback training will involve the use of one or more of the following: the Wild Divine Project s software and hardware, a stress thermometer, HeartMath (EM Wave) software and hardware, a Pulse Oximeter, and or Resperate. Sensors may be placed on the fingers, ear lobes, waist, skin, or forehead. Areas where sensors may be placed will be prepped with an alcohol prep pad. Consent for Treatment ~ Page 3

4 The benefits of Peripheral Biofeedback include but are not limited to improved self regulation and control, increased relaxation, reduction in stress/tension, anger management, overcoming certain fears, sleep problems, and improved vital signs (i.e., reduced heart rate, lower blood pressure, slower/rhythmic breathing, reduced muscle tension. Biofeedback is often used to treat headaches, migraines, pain, anxiety, reducing problem behaviors, and other disorders. In some cases medications being used to treat certain disorders might be reduced in dosage or eliminated based upon the patient having a doctor review the existing condition and symptoms. The risks of Peripheral Biofeedback may include uneasiness in learning and viewing one s vital signs, and frustration when learning proper biofeedback techniques. Biofeedback will not interfere with most other treatments. The patient may feel tired/sleepy or physically heavy as a result of participating in Biofeedback. It is also possible that the patient might fall asleep during or after Biofeedback sessions. The risks of not participating in biofeedback include continuation of presenting problem and/or symptoms. Alternative treatments to biofeedback include, mental health counseling, neurofeedback, CES, AVE, medicines, alternative health care options (i.e., acupuncture, natural supplements), physical therapies and other additional medical treatments and procedures. Neurofeedback / EEG Biofeedback / Neurotherapy/ Bioneurofeedback Neurofeedback is a treatment technique that presents the patient with real-time feedback on brainwave activity, as measured by sensors on the scalp, typically in the form of a video display and sound. When brain activity changes in the direction desired by the neurofeedback protocol, a positive "reward" feedback is given to the patient. Rewards/reinforcements can be as simple as a change in pitch of a tone or as complex as a certain type of movement of a character in a video game. The characteristic that distinguishes neurofeedback from other biofeedback is a focus on the central nervous system and the brain. Neurofeedback has its foundations in basic and applied neuroscience as well as data-based clinical practice. It takes into account behavioral, cognitive, and subjective aspects as well as brain activity. Several electrodes/sensors are placed on the scalp and earlobes. The sensors detect brain wave activity including Delta, Theta, Alpha and Beta. Individual brainwaves are measured and revealed on a computer screen in order to see brainwave activity. Through instruction the patient learns to train down or train up certain brainwaves Consent for Treatment ~ Page 4

5 associated with anxiety, depression, fear, relaxation, ADHD, trauma, and other clinical areas of interest. Treatments last from minutes and may occur two or more times per week for a minimum of sessions. For some conditions, such as Autism, or more sessions may be required in order to determine benefits from neurofeedback. Neurofeedback consists of placing one or more electrodes on the patients scalp and ear clips on one or both ear lobes. Each electrode site will first be cleansed will be prepped with NuPrep and/or an alcohol prep pad. Electrodes will be attached to the scalp using 10/20 Electrode Paste. The patient sits in a reclining chair and is asked to relax with eyes closed while listening to sounds or tones; or with eyes opened while watching visual stimuli on a computer monitor and listening to sounds, tones, music or sound tracks to videos. Preparation takes approximately 10 minutes and the actual neurofeedback sessions take anywhere between minutes, or more in some cases. Neurofeedback treatments will involve the use of the BrainMaster software and hardware including a BrainMaster Atlantis 4X4 as well as electrodes, and 10/20 Electrode Paste. NOTE: In order to engage in neurofeedback, you will first be required to have a neurological assessment (QEEG). It is also important to understand that many neurofeedback protocols are considered to be experimental. There are several disorders that may respond positively to neurofeedback and neurofeedback includes many potential benefits. Neurofeedback has published effectiveness for the treatment of a variety of disorders including ADD/ADHD, Addictions, Anxiety, Chronic Pain, Cognitive Enhancement, Depression, Epilepsy, Fibromyalgia, Learning Disabilities, Peak Performance/Academic Performance, PTSD, Relaxation, Sleep Problems, and Stress. Neurofeedback also has demonstrated clinical effectiveness for many disorders including Autism, Bipolar Disorder, Brain Injury (TBI), Cognitive Decline, Headache, Migraines, Obsessive Compulsive Disorder, Stroke, Turret s Syndrome, In addition neurofeedback has been shown to be useful in treating Anger, Asthma, Autoimmune Disorder, Cerebral Palsy, Creativity, Chronic Fatigue Syndrome, Coma, Developmental Disorder, Dissociative Disorder, Hypertension, Optimal Functioning, Parkinson s, Premenstrual Syndrome, Spasticity, Tinnitus, & TMJ. The risks of neurofeedback include increased dreaming and recollection of dreams, nightmares, boundary clarification (relationship changes), an occasional headache, moodiness, irritability, and, neurofeedback reduces the ability to resist emotions. Consent for Treatment ~ Page 5

6 Neurofeedback will not interfere with most other treatments. The patient may feel anxious as a result of participating in neurofeedback and seeing their own brain activity, or may feel tired/sleepy or physically heavy as a result of participating in neurofeedback.. Temporary side effects such as feeling giddy, agitated or irritated may occur during neurofeedback sessions; however, these side effects can be adjusted and eliminated immediately in most cases. It is also possible that the patient might fall asleep during or after neurofeedback sessions. The risks of not participating in neurofeedback include continuation of presenting problem and/or symptoms. Alternatives to neurofeedback include mental health counseling, peripheral biofeedback, medicines, alternative health care options (i.e., acupuncture, natural supplements), physical therapies and other additional medical treatments and procedures. Cranial Electrotherapy Stimulation (CES) Cranial Electrotherapy Stimulation (CES) is a treatment for anxiety, depression, insomnia, stress and drug addiction which utilizes small pulses of electric current (ma) across a patient's head. CES is also known as Transcranial Electrotherapy (TCET) and Neuroelectric Therapy (NET), but should not be confused with Electroconvulsive Therapy (ECT) which uses higher levels of electricity to produce therapeutic convulsions. Generally, electrodes are placed on or near a person's ears to pass low level electricity through the brain; the person remaining awake and alert during the whole process. CES can relieve anxiety for limited periods, though the mechanism of its efficacy is not known. CES may be used as an adjunct to anxiolytic medication and/or psychotherapy. CES is an FDA approved treatment. The treatment is very simple. The current is applied by clip electrodes that attach on the ear lobes. A small electrical current (powered by a 9 volt battery) set at 0.5Hz passes into the electrode and, will effect a balancing of the patient s neurotransmitters by stimulating the brain to make more of the neurotransmitters the patient does not have enough of, until the patient s level has increased to the extent they and the other neurotransmitters can mutually control each other's production. The average CES session lasts between 20 to 60 minutes every day, every other day, or on an as-needed basis for a minimum of sessions. CES can help induce a pleasant, relaxed feeling of well being. The use of CES is based on the concept that the biophysics underlying the body s biochemistry also plays a significant role in regulating all of life s processes. CES proprietary waveform works by moving electrons through the body Consent for Treatment ~ Page 6

7 and brain at a variety of frequencies, collectively known as harmonic resonance. This normalizes the electrical activity of the nervous system and brain as measured by an electroencephalogram (EEG). The patient may feel a slight tingling sensation under the electrodes, but it is not necessary to feel this in order to achieve results. Most people feel nothing at all except positive results. Since CES works at a level of electricity similar to the body's own bioelectricity, no known harm can come from its use and/or overuse. Neurotherapy will not interfere with most other treatments. The equipment used is either the Alpha-Stim 100 or the David Delight Pro. The Alpha-Stim 100 treats anxiety, depression, and/or insomnia with microcurrent. The benefits of CES are that it is well tolerated and very safe in contrast to drugs used in the treatment of mood disorders, many of which have been proven to have undesirable side effects and can be addictive. Unlike drugs, CES leaves the mind alert. CES is known to assist most patients by decreasing symptoms associated with depression, anxiety, and insomnia. Anxiety reduction is usually experienced during each treatment; but may be seen hours later, or up to 24 hours after treatment (one 20 minute session may reduce anxiety for up to twenty-four hours). Other benefits include the possibility of reducing problem behaviors and relief from pain. Depression and insomnia control is generally experienced after one to two weeks of daily treatment. CES can also help treat the underlying mood disorders associated with pain. It may be used as an adjunct to medication and/or psychotherapy. After treatment, there are usually no physical limitations imposed so the majority of people can resume normal activities immediately. Maintenance of a relaxed, yet alert state is generally achieved with treatments three times per week. CES is widely regarded as safe and effective alternative treatment modality to pharmacotherapy. Risks associated with CES include side effects that may include headache, lightheadedness, or skin irritation by electrodes. Patients may feel a tingling/pricking feeling/sensation in their ear lobes. It is also possible that the patient might feel dizziness or nausea. These symptoms can be corrected by decreasing the intensity setting and will go away immediately. Mild headaches have been reported in some patients and these headaches go away within a few hours. It is possible that CES may result in the patient having dreams and/or experiencing negative memories and/or feelings. Skin irritation may develop from the electrode pad solution if the ear lobes are not cleaned properly after treatment. CES may effect the operation of cardiac pacemakers. CES is usually not recommended for people with a history of epilepsy or seizures. Consent for Treatment ~ Page 7

8 CES will not interfere with most other treatments. The patient may feel tired/sleepy or physically heavy as a result of participating in CES. It is also possible that the patient might fall asleep during or after CES sessions. The risks of not participating in CES include continuation of presenting problem and/or symptoms. Alternatives to CES include mental health counseling, peripheral biofeedback, neurofeedback, AVE, medicines, alternative health care options (i.e., acupuncture, natural supplements), physical therapies and other additional medical treatments and procedures. Audio-Visual Entrainment (AVE) Audio-Visual Entrainment (AVE) is a technique that provides light pulses complimented by sound at specific frequencies, tones and beats, via a portable Audio- Visual Entrainment (light & sound therapy) device. Using flashes of lights and pulses of tones, AVE safely guides the brain into various brain wave patterns. Brainwaves change frequencies based on neural activity within the brain. Each of our senses (vision, touch, smell, taste and hearing) respond to activity from the environment and transmit that information to the brain. The senses of sight and hearing, by their very nature, provide a favorable mechanism to influence brainwaves. By presenting this pulsed audio and visual stimulation to the brain, after a short period of time, the brain begins to resonate, or entrain, at the same frequency as the stimulus. AVE can slow down the brainwaves for meditating, inducing dream states and improving sleep. AVE can also be used to speed up brainwaves to help with improving mood, enhancing mental performance and boosting creativity. In addition to entrainment, the imagery created by the visual and auditory stimulation provides a focus for the mind and quiets internal dialogue or chatter. AVE is conducted by the use of a hand held device, the David Delight Pro. The patient places a set of photo-stimulating glasses on, like a normal pair of eye glasses. The photo-stimulating glasses produce flashing white or colored lights. The patient may keep their eyes opened or closed depending on which is most comfortable. In addition the patient places a headset on which produces binaural sounds in conjunction with the photic stimulation. Consent for Treatment ~ Page 8

9 AVE has several benefits and can be used to treat a variety of disorders including but not limited to stress reduction, anxiety, depression, sleep disorders, headaches & migraines, attentional problems and other disorders. Based on the desired change in behavior the light and sound pulses enhance the production of the specific brain wave frequency targeting the desired behavior(s), settles down an agitated mind, increases cerebral blood flow and increases the metabolism of glucose in the brain for improved neuronal function. AVE is not only valuable for clinical use, but can also be used for increasing peak performance and for relaxing and visualizing. Risks associated with AVE include sensitivity to and discomfort with the photic stimulation, headaches, and seizure. Epileptics should NOT use any AVE without the consent of their physician. Persons with a history of brain seizures, mental disorders or alcohol and/or drug abuse should also not use the AVE unless first consulting their medical doctor. AVE is not recognized as a treatment or cure of any medical condition or disability. However, research suggests that AVE is an effective relaxation and meditation tool. The risks of not participating in AVE include continuation of presenting problem and/or symptoms. AVE will not interfere with most other treatments. The patient may feel tired/sleepy or physically heavy as a result of participating in AVE. It is also possible that the patient might fall asleep during or after AVE sessions. Alternatives to AVE include mental health counseling, peripheral biofeedback, neurofeedback, CES, medicines, alternative health care options (i.e., acupuncture, natural supplements), physical therapies and other additional medical treatments and procedures. Holistic Health The above treatments cannot help the patient s brain make neurotransmitters, if the building blocks for them are not present in the blood stream. Therefore, it is very important for the patient to eat a balanced diet while in treatment, and that includes the major amino acids, vitamins, minerals, and other micronutrients. The mediteranian diet is strongly recommended. Patients should also drink plenty of water as it is necessary for electrical conductivity in the body. It is advised that patients not consume any alcoholic beverages the same day as treatment. Consent for Treatment ~ Page 9

10 In addition to eating a healthy, it is important to participate in routine exercise and establish a routine sleeping pattern (i.e., going to bed approximately the same time every night and getting up approximately the same time every morning). A minimum of 7-8 hours of sleep per night is strongly recommended. Choosing Treatment None of the above treatments are mandatory. The patient will not be pressured to enter treatment, nor for not participating in treatment. The patient may withdraw from/stop any of the above treatments at any time without consequence. Consent for Treatment ~ Page 10

11 Robert E. Longo, MRC, LPC, NCC Serendipity Healing Arts Board Certified in Neurofeedback Consent to Treatment I voluntarily consent to participate in and undergo the treatment methods and modalities checked and initialed below, and hereby release Robert E. Longo, Integrative Therapies, Serendipity Healing Arts and its counselors, therapists, technicians, independent contractors, and other employees from any and all liability which may occur in connection with the above mentioned treatments/therapies. I understand that I am free to withdraw my consent and to discontinue participation in the treatment modalities/methods checked below, at anytime. I have been informed that the professional staff working with me are not medical doctors, but are specially trained personnel. The natural consequences and potential risks and benefits have been fully explained to me by Robert E. Longo. I have checked and initialed the treatments I wish to participate in below: Neurological QEEG Assessment Peripheral Biofeedback Cranial Electrotherapy Stimulation (CES) Audio Visual Entrainment (AVE) Neurofeedback Initials Initials Initials Initials Initials My signature below indicates that I have discussed the procedures/treatments I am consenting to with my treating professional. I have read the Consent for Treatment form; or I have had the form and its contents read to me (or my legal guardian) and explained to me. My signature below indicates that I am voluntarily consenting to assessment and/or treatment as described in this form. I understand I may ask questions at any time, and may request to stop treatment at any time. Patient Signature Parent/Guardian (if patient is under 18) Clinician Signature Date Date Date Consent for Treatment ~ Page 11