Get the free Neurofeedback Referral Form - Oregon Natural Medicine
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1724 NE 42nd Ave Portland, OR 97213 Phone: 5039468700 Fax: 5034063000 info OregonNaturalMedicine.com Neurofeedback Referral Form Patient Name: Date of Birth: Phone: Referring Provider Name: Referring
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How to fill out neurofeedback referral form
How to fill out a neurofeedback referral form:
01
Start by filling out your personal information, including your full name, date of birth, contact information, and address. This information is important for healthcare providers to identify and reach out to you.
02
Provide your current medical history, including any relevant diagnoses or conditions you have been diagnosed with. This information will help the neurofeedback provider understand your specific needs and tailor the treatment accordingly.
03
Indicate any medications you are currently taking. This is crucial as certain medications can potentially interfere with neurofeedback treatment or require adjustments in the protocol.
04
Specify your reason for seeking neurofeedback therapy. It is important to clearly communicate your symptoms, concerns, or goals to the provider, as they will use this information to develop an effective treatment plan.
05
If you have any previous experience with neurofeedback or other forms of therapy, make sure to mention it on the form. This allows the provider to have a better understanding of your background and potential treatment approaches that have worked for you in the past.
06
If you have any known allergies or sensitivities, be sure to include them on the form. This will help ensure the safety and suitability of the neurofeedback sessions.
07
If applicable, provide information about your insurance coverage. Some neurofeedback providers may require insurance information for billing purposes, so make sure to fill out this section accurately and completely if necessary.
08
Finally, sign and date the referral form to indicate your consent and agreement. By signing the form, you acknowledge that you understand the nature of neurofeedback therapy and that you authorize the release of any relevant medical information to the provider.
Who needs a neurofeedback referral form?
01
Individuals seeking neurofeedback therapy to address specific mental health or neurological conditions.
02
Clinicians or healthcare providers who are referring their patients to a neurofeedback specialist for further assessment or treatment.
03
Insurance companies or third-party payers who require a referral form as part of the authorization process for coverage of neurofeedback services.
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What is neurofeedback referral form?
Neurofeedback referral form is a document used to request a neurofeedback session for a client.
Who is required to file neurofeedback referral form?
Healthcare professionals, therapists, or clinicians who are recommending neurofeedback therapy for a client are required to file the referral form.
How to fill out neurofeedback referral form?
The form typically requires information about the client's medical history, current symptoms, and the reason for recommending neurofeedback therapy.
What is the purpose of neurofeedback referral form?
The purpose of the form is to provide necessary information about the client to the neurofeedback provider to ensure a safe and effective treatment plan.
What information must be reported on neurofeedback referral form?
Information such as client's name, age, medical history, current symptoms, previous treatments, and any underlying conditions must be reported on the form.
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