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830 N. Theatre Road, Suite B, Marion, IN 46952
(765) 661-5708
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830 N. Theatre Road, Suite B, Marion, IN 46952
(765) 661-5708
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WHO WE ARE
Testimonials
WHAT WE DO
Addiction
ADD & ADHD
Autism
Brain Fog
Concussion Mitigation
Depression & Anxiety
Migraines
PTSD
HOW WE DO IT
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Client Review Request
2023-08-18T09:01:28-04:00
Patient Review (Private Form)
Client Code
Client DOB
MM slash DD slash YYYY
Brain Map Date
MM slash DD slash YYYY
Client Diagnoses or Chief Complaints (select all that apply):
Anxiety
Depression
PTSD
ADD/ADHD
Migraines
Post-Concussion Syndrome
Behavioral Issues
Autism
Addiction
Peak Performance Only
Briefly Explain Client Diagnoses or Chief Complaint
Is client currently taking prescription medications or supplements?
Yes
No
List Medications and/or Supplements
Does client use recreational drugs or alcohol?
Yes
No
List drug type and frequency / List alcohol amount and frequency:
Upload Client Brain Maps (EO sLoreta Summary and Linked Ears, EC sLoreta Summary and Linked Ears, Neuroguide)
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