LifeWorks Resources, LLC

I understand that I have the right to information about the Alpha-Stim treatments. I have been provided information and have discussed the use of Alpha-Stim with my therapist and I understand the potential benefits and minimal risks associated with this therapy.

1. Alpha-Stim may provide substantial relief for the indicated treatments of anxiety, insomnia, depression and pain. Some individuals may experience noticeable results after a single treatment while others may require more frequent treatments for a longer period before desired results are achieved.
2. Alpha-Stim may produce mild and self-limiting adverse effects such as slight dizziness, slight skin irritation (physical contact includes a conducting solution attached with ear clips or probe at the electrode site), or a mild headache. Prolonged treatments at currents higher than necessary may cause dizziness or nausea that can last for varying durations. A reduction in current levels can eliminate these reactions.
3. Alpha-Stim is contraindicated for use with individuals with implanted demand-type pacemakers and implanted defibrillators AND with women who are pregnant.
4. As with any therapeutic intervention, not all people will respond to AlphaStim. Available alternative interventions may include but are not limited to, counseling and acupuncture among others. The degree to which an individual will respond depends on the nature of the problem being treated, the overall health of the person, and with the method of treatment. Additional treatments may be necessary to reach the desired results.
5. Provider maintains the right to discontinue Alpha Stim if in the providers best clinical judgement the psychological risks of further treatment out weight the benefits.
6. I understand that I have the right to information about the professional capabilities, specialization, education and training of the named clinician to his/her use of the AlphaStim.
7. In signing this consent form, I am stating that I fully understand and agree to the AlphaStim treatment that I will receive. I also understand that I can terminate the Alpha-Stim treatments at any point.