ACORN HEALTH ASSOCIATES, P.C.

www.acornhealth.com 4410 Linglestown Road Harrisb rg! "# 1711$ FNS/LENS Treatment Consent Areas of applicabilit ! 'he (le&)& *e ro%eedbac+ ,)stem -(*,. and L/*, have been s ccess% ll) a00lied to central nervo s s)stem 0roblems! s ch as s)m0toms o% tra matic brain in1 r)! stro+e! %ibrom)algia! de0ression! mood disorders -other than de0ression.! attentional disorders! h)0eractivit)! e&0losiveness! anger! and learning 0roblems. 2ontrolled st dies o% (*,3L/*, have been com0leted and other st dies are ongoing. Effects of FNS/LENS! (*,3L/*, tends to ma+e % nctioning clearer and easier. 'reatment has increased cognitive % nctioning -memor)! concentration! attention! abilit) to learn and to read! organi4ing! and se5 encing.! motivation -initiating and com0leting activities.! and motor s+ills -coordination! balance! grace! decreased s0asticit)! im0roved tone and movement.. (*,3L/*, a00ears to wor+ as an antide0ressant! elevating the moods o% de0ressed 0ersons. ,lee0 disorders have been ameliorated with im0roved slee0 at night and red ced slee0iness d ring the da). 6t has increased energ) and stamina. /&0losiveness! irritabilit)! and bac+gro nd an&iet) have been red ced. "ain d e to migraines! %ibrom)algia and other centrall) mediated 0ain disorders have been red ced. "roblems with Restless Leg ,)ndrome have been alleviated. Si"e effects! *o signi%icant negative side e%%ects have been observed. 'he side e%%ects that have been noted will be disc ssed with )o . 'he side e%%ects sometimes seen with (*,3L/*, are in the %orm o% tem0orar) increases o% the s)m0toms )o alread) have or 0erha0s s)m0toms that )o have e&0erienced 0revio sl). "lease re0ort all side e%%ects to )o r (*,3L/*, 0ractitioner so that he3she can wor+ closel) with )o to ad1 st the dosage. 'his is done the same wa) )o r medications are ad1 sted with )o r 0h)sician. 7o r willingness to disc ss an) 0ossible side e%%ects and to nderstand how the) change over time will hel0 )o wor+ with s to 0rovide s ccess% l treatment. #e"ical stabilit ! 7o m st be medicall) stable to engage in this treatment. "lease tell )o r 0ractitioner i% )o have an) changes in medication or an) change in other thera0ies )o ma) be 0artici0ating in. Re0orting an) change in s 00lements or vitamins will also be im0ortant. # change in )o r res0onse to )o r t)0ical medication regimen sho ld also be disc ssed with )o r (*,3L/*, 0ractitioner. /&0erience with this treatment technolog) will allow )o r 0ractitioner to cons lt )o r 0h)sician abo t 0ossible medication ad1 stments that ma) s0eed recover). Ot$er treatments! # n mber o% di%%erent %orms o% ne ro%eedbac+ e&ist. #t this time their relative e%%ectiveness has not been st died. %iscontin&in' treatment! 7o ma) discontin e treatment at an) time %or an) reason. ,ho ld )o wish to discontin e treatment 0lease in%orm )o r 0ractitioner. # disc ssion o% the reasons %or discontin ation 0rovides s with val able in%ormation abo t treatment e%%ectiveness and side e%%ects. 'his disc ssion wo ld also allow a00ro0riate re%errals i% )o desire. Pri(ac ! 7o r treatment records will be +e0t 0rivate to the % llest e&tent o% the law. 2on%identialit) can be violated in the %ollowing circ mstances8 -1. )o are 1 dged to be a danger to )o rsel% or others! -$. a co rt order re5 ests the records in a civil or criminal case. S&ccess rate! 9eca se 0eo0le are individ als! s ccess with (*,3L/*, is best 0redicted with a com0lete eval ation and the develo0ment o% a treatment 0lan. 'he eval ation allows s to 0redict which s)m0toms will res0ond! and which ma) res0ond %irst. #s with an) treatment there can be no g arantee o% s ccess. Consent to treatment! 7o are invited to consent to be treated on the basis o% this in%ormation. 9e%ore )o give )o r consent to be treated! we want )o to as+ as man) 5 estions as are necessar) %or )o to nderstand this 0rocess. "lease contin e to e&0ress )o r 5 estions! observations! and concerns at an) time d ring the treatment 0rocess. I have been informed of the effects, side effects, benefits, and risks of this treatment, and give my consent to participate in it. ::::::::::::::::::::::::::::::::::::::::::::: *ame :::::::::::::::::::::: ;ate 717-545-1938 voice 717-545-1948 %a&