Here are some forms that are used regularly at the clinic. Send the forms to the clinic via fax, e-mail, or mail. Please USE A BLACK FELT-TIPPED PEN for filling out any forms for faxing, scanning, or copying. Anything else may be illegible if you scan it or fax it.
901-763-0999 Voice
901-328-1592 Fax
Office Location--
5575 Poplar Avenue, Suite 420
Memphis, TN., 38119 Map to the Office
Mailing Address-- Correspondence, insurance, payments, etc:
4728 Spottswood #361, Memphis, TN 38117
Instructions for filling out the forms
Special Forms for Neurofeedback Patients
Intake for Children (Under 18) Print it , fill it out, and get it to the clinic at or before our first EEG Biofeedback visit.
Intake for Adults (18 0r 0ver) Print it , fill it out, and get it to the clinic at or before our first EEG Biofeedback visit.
Forms for Psychotherapy/Counseling Patients
Forms for Everyone
Contact Info Form EVERYONE needs to fill out one of these. Please use a black pen-- this one will be faxed to my insurance service, so it needs to be readable.
Release of Information Form We need one of these filled out and signed by you for each healthcare provider or educational professional that we need to consult with regarding the treatment you receive with Dr. Heegel.
Informed Consent You don't really have to print this one out, but it is REQUIRED READING for all who have a professional relationship with Dr. Cliff at the Stress, Trauma, and Biofeedback Clinic.
HIPAA (Privacy Act Info--Required Reading Federal Law) You sign these things pretty much anytime you go see a new doc. This is required for everybody.
These forms are in Adobe Acrobat (PDF) Format. To view them you will need Adobe Acrobat Reader. You can get a free copy by visiting the Adobe website here.