Pre-Screening Questionnaire for Brain-Based Therapies

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DBA Cereset West Las Vegas

Cereset Pre-Screening Questionnaire

This form is designed to gather important information regarding your current health status, treatments, and sensitivities. Your responses will help us determine your eligibility for various brain-based therapies and ensure that we provide you with the most appropriate care tailored to your needs.

Please take a moment to answer each question honestly and thoroughly. Rest assured that all information provided will be kept confidential and will comply with HIPAA regulations to protect your privacy. Your information will be used solely for the purpose of assessing your qualifications for treatment options.

Thank you for your cooperation. We look forward to supporting you on your journey to better health!

First name*

Last name*

Email*

Phone*

1. Do you currently have a Deep Brain Stimulation (DBS) implant?*

Yes

2. Are you currently using any other brain-based therapies, including but not limited to ECT, EMDR, neurofeedback, biofeedback, and/or listening programs such as the MUSE and binaural beats?*

Yes

If "Yes" please explain.

3. Are you currently using any other treatments, therapies, or modalities, brain-based or otherwise, including holistic remedies?

Yes

If "Yes" please explain.

4. Do you drink alcohol, use marijuana (including medical marijuana) or recreational drugs?

Yes

5. Do you currently take any medications or supplements?

Yes

If "Yes" please explain.

6. Do you have a history of TBI (traumatic brain injury) or concussion.

Yes

7. Do you have a history of a chronic or long-term illness or disorder (i.e., Lyme disease, seizures, cancer, migraines, fibromyalgia, depression, bi-polar disorder, etc.)?

Yes

If "Yes" please explain.

8. Do you consider yourself sensitive in nature? Sensitivities could include the moods and emotions of yourself and/or others, foods, medications, allergens and pollutants, environmental changes?

Yes

If "Yes" please explain.

9. Do you have any major/current ongoing stressor in your life?

Yes

If "Yes" please explain.

About Us

At Bargamento Wellness, our mission is to empower individuals to achieve mental clarity, reduce stress, and restore hope through advanced, non-invasive technology that naturally balances and harmonizes brain activity. By focusing on enhancing brain function, we facilitate deep relaxation and promote restful sleep, supporting overall mental health and well-being.

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