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CereMind - Gateway

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PRODUCTS	PRICE	CURRENCY	TOTAL
CereMind - Gateway	$1997.00		$1997.00
Subtotal			$1997.00
Total due			$1997.00

PRODUCTS CereMind - Gateway
PROGRAM PRICE $1997.00	$1997.00
TOTAL	$1997.00
Subtotal	$1997.00
Total due	$1997.00

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Participant Date of birth (this is used to make sure the user is assigned the correct program)

Enter Agency / Representative Code / Doctor / Clinic Name

Is the participant aged 18+ years?

Is the participant able to safely perform physical activities for approx. 10 minutes daily? Exercises involve movements such as standing on one leg, marching, turning, bending at the waist. If unsure please consult a medical Doctor.

Does the participant have any injuries, diagnosis, conditions or information of importance that may affect their ability to perform exercises safely (this includes pregnancy)? If unsure please consult a medical Doctor.

If you are currently involved in other therapies (particularly talk therapies) please be aware that it could potentially conflict with or impact your progress in Self-EMDR, do you wish to proceed?

This program will explain how to use the software for the Self Guided EMDR process. The responsibility for ensuring suitability for the process and also any support required during the process is with the user. However it is specifically not recommended to use of Self-EMDR with a current or recent episode of clinical depression, suicidality, psychosis, bipolar disorder, schizoaffective or dissociative disorders, borderline personality disorder or unstable substance abuse. These conditions require treatment supervised by an appropriately qualified mental health specialist. Please confirm that you fully understand this and wish to proceed.

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Medicare Advantage Plans such as Blue Cross, Aetna, United & Humana are not currently covered

Insured's I.D. Number Does the participant agree to participate in 2-3 telephone coaching sessions per month, each lasting about 5-7 minutes, with a certified coach as part of the overall program?

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