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Neurofeedback Permission Form

Tanya Thomas Therapy

7 Bell Yard

Mobile: 07773097809

Neurofeedback Permission Form

By signing below, I acknowledge that I have read, understood, and agreed to the following:

I. I authorize Tanya Thomas and her staff to obtain and share my personal and protected health information (PHI) with Divergence Neuro Technologies Inc. for purposes of coordinating and facilitating my neurofeedback training protocol(s). This information includes my full name, birthdate, email address, and phone number, all of which I have provided to Tanya Thomas and her staff via my patient profile and intake forms. It also includes information from my intake questionnaire as well as Tanya Thomas’s discussions with me regarding my goals and presenting issues/concerns for training.

II. This authorization remains effective from the signature date below until the date on which my receipt of services from Tanya Thomas terminates, at which time this authorization expires.

III. There shall be no sale or transfer by Divergence Neuro of the information/data collected, unless expressly permitted to by the user, or we must fulfil an obligation to that user with a partner (third party). For more information on their privacy policy, please follow the link provided: Divergence Neuro Privacy Policy

IV. I have the right to revoke this authorization at any time and must do so in writing. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization.

V. I understand that neurofeedback is an education and training procedure. it is not a form of psychotherapy or any other regulated psychological service.

VI. If necessary, Tanya Thomas will refer me to an appropriate third-party healthcare provider.

Please format as MM/DD/YYYY eg: 01/02/2024

Neuro Intimate (2024) C TanyaThomasTherapy Ltd