TRAINING AND FEE GUIDELINES AND DISCLOSURE I acknowledge I have read, understand, and are able and willing to work within these guidelines. Please read the following carefully. If you decide to receive NeurOptimal® training with us, these policies will guide our work together. 1. Fees are due at time of service. Fees are paid at each session or in advance. We do not work with insurance or submit to third parties. There may be special discounts available for prepayment of blocks of sessions. These pre-payments are not refundable but may be transferred by mutual agreement. Please note, however, it is always our decision whether to accept a particular individual for training or not. 2. Session length is about 50 minutes, so you will typically be in and out within the hour. It is not a problem if you arrive late, but the session will need to finish at its appointed time. We will work with you to provide the maximum training we can in the time we have. 3. We have a 24-hour cancellation policy. If you cancel less than 24 hours before the start of your session, we require you to be financially responsible for the session. This means you need to call 24 hours before the start of the session (not the “night before”) to not incur charges. While we can – and do – feel personally empathetic to issues that can arise, please consider your booking like a concert ticket. Feel free to use it or not, as it supports your best interests at the time. 4. We do not provide emergency coverage and may not be available for blocks of time, such as weekends or holidays. You are welcome to call us between 8 am and 8 pm any day of the week or email us at any time, and we will get back to you as soon as we are able. 5. Fees for sessions are as follows: Single session $60.00* 10 sessions $500* 20 sessions $900 * Forms of payment we accept are cash and major credit cards (VISA, MC, AMX) Please acknowledge below that you have read, understood and are able and willing to work within these guidelines. Agree Disagree Client Name * First Name Last Name Thank you! I acknowledge I have read and understand the following disclosure. I understand that NeurOptimal® is not a medical treatment, device or methodology. It is not used to diagnose medical disorders nor is it used as a medical treatment for disorders and has not been approved for any medical purpose by the FDA, Health Canada or any other governing agency. While Zengar trainers may or may not be licensed health care practitioners, their use of NeurOptimal® is solely as a tool for brain training and optimization and not as a means of diagnosis or as a medical intervention. I am satisfied with the information I have been provided (verbal, written or otherwise) by my trainer on the effects I can expect during my NeurOptimal® training and my questions have been answered to my satisfaction. I understand that it is not possible to predict what my central nervous system will do with the information it is offered and consequently there can be no guarantee as to the results of my training. I agree to cease training if I am less than happy with the results I am getting. I understand NeurOptimal® is purely a source of information and does not direct the response of the central nervous system. Consequently, I agree to not hold Zengar Institute Inc, Texarkana Neurofeedback LLC, or any of its users and trainers responsible for a less than desired outcome or any outcome that may be considered negative. Agree Disagree Client Name * First Name Last Name Thank you! Consent to Train with NeurOptimal® Client Name * First Name Last Name Parent/Guardian First Name Last Name Date of Birth * MM DD YYYY School Grade PreSchool / Pre-K Kindergarten 1st 2nd 3rd 4th 5th 6-8th 9-12th Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Concerns * How did you hear about us? Thank you!
