Biocybernaut Confidential Information Form


Please fill out this form completely and return it within one week. We will hold the information on this form in the strictest confidence.

Please answer every question and sign your name where appropriate. 

1.) Training Location:

2.) Name: (Last) (First)  

3.) HomeAddress: (Street)   (City) (State/Province) (Postal Code) 

4.) Phones (Home) (Work)  

(Cell) (Emails)  

6.) Time of Birth  

(Birth Location)  

7.) Sex: Handedness: Blood Type  

8.) Marital Status (check all that apply):

 9.) Occupation or Profession:  

Job Title or Position:  

To participate in the Biocybernaut Institute of Arizona, LLC Brain Wave Training you must be at least 8 years of age. If you are over 8 but under 18 years of age, your parent or legal guardian must approve your participation. If you are under 12 years of age you must have a parent, guardian, or other relative taking the training with you.

 

 

10.) How were you introduced to the Biocybernaut Institute? 

 

Name of the Above:  

11.) Please describe what you would like to accomplish through your Biocybernaut Institute Brain Wave Training. Be as specific as you wish.

 

12.) Is there anything else you would like to communicate or have your Biocybernaut Institute Trainer know about you?

 

Confidentiality Agreement: I understand that the Biocybernaut Institute Brain Wave Training is a personal experience. Although I am free to talk about my own experiences, I agree to hold confidential the names and remarks of any others who are participating with me in the Training. 

 

Before participating in the Biocybernaut Institute Brain Wave Training programs you must read the following information, and sign your name at the end of this form to indicate the accuracy and truthfulness of your answers to the questions herein and to indicate your agreement with, and your full and enthusiastic assent to, all the terms and conditions hereof. 

The Biocybernaut Institute Brain Wave Training is an educational and research program in brain wave biofeedback designed by Dr. James V. Hardt, and utilizing a computer-based learning technology. Trainee acknowledges his/her understanding of the educational and research nature and purposes of this training, and Trainee acknowledges his/her understanding that the research procedures and protocols herein employed were developed by Dr. Hardt, reviewed and approved annually by the Committee on Human Research at the University of California, and were used for 12 years by Dr. Hardt (1976-1988) at UCSF during Dr. Hardt’s research work at the Langley Porter Neuropsychiatric Institute at the University of California at San Francisco, USA. 

Trainee acknowledges that he/she wishes to participate in this training program of his or her own free will. There is no assurance of any beneficial or therapeutic result from this EEG research and education training, and careful records will be kept to determine if there is any beneficial outcome. Periodic two or three-day follow-up training are recommended once or twice during the 6 months following completion of the Level 1 Training to assess and to help maintain the permanence of any beneficial results that may occur, but these “tune-ups” are not required and they are not within the scope of this Training Agreement. 

People often find that after the training they have a greater awareness, useful insights, an enhanced sense of well-being and that certain physical problems dissipate or actually disappear. However, we wish to be absolutely clear and to have your full understanding that the training is not a form of therapy or practice of medicine. The training is not a substitute for the services of a professional therapist or a medical doctor. The Biocybernaut Institute Trainers who facilitate the training are not professional therapists or medical doctors. They are biofeedback practitioners and are certified by the Biofeedback Certification Institute of America and/or by Biocybernaut Institute, Inc. Please note that neither professional therapists nor medical doctors are in attendance at the Biocybernaut Institute Brain Wave Training. Given the nature of the Biocybernaut Brain Wave Training Program, we have additional questions and certain recommendations to make regarding your participation: 

 

13.) If you are currently in the care of a professional psychotherapist or medical doctor, we require that you discuss your participation with them before participating in the program, in order to determine that the Brain Wave Training Program will not interfere with any work you are already doing with them. 

A.) Are you currently in the care of a professional psychotherapist?  

B.) Are you currently in the care of a medical doctor:  

C.) If you answered “Yes” to either of the above two questions, or “Yes” to both of them, 

please state specifically the condition or conditions for which you are being treated. 

i.) Did you discuss your participation with your psychotherapist?  

ii.) Did you discuss your participation with your medical doctor?  

iii.) Does your psychotherapist support your participation in the training?  

 iv.) Does your medical doctor support your participation in the training?  

*** If your medical doctor and/or your psychotherapist do not support your participation, or have not been given the opportunity to hear of and then to support your intention to take the Biocybernaut Institute Brain Wave Training, (if you answered “No” to any of the questions above: 13-C-i, 13-C-ii, 13-C-iii, or 13-C-iv), then we recommend that you DO NOT TAKE the brain wave training program at this time.

Please call us immediately at (928) 203-9000 if you have any questions or if you do not have your psychotherapist’s or your medical doctor’s support. 

14.) Do you currently have a medical or psychological condition for which you are not now receiving medical treatment?  

If “Yes”, please state specifically what condition(s). 

15.) A) Do you presently have an active case of a socially communicable disease, 

such as tuberculosis, hepatitis, influenza?  

Do you have now or have you ever had any the following below?  

*^* If you have answered “Yes” to any of the items in question 15.) above, please CONTACT US IMMEDIATELY TO DETERMINE THE APPROPRIATENESS OF YOUR PARTICIPATION IN THE TRAINING

16a.) In the process of the training you may recall some past experiences which produced stress, anxiety, or sadness, as well as recalling experiences which were satisfying, joyful, romantic, and exhilarating. You may experience these emotions, and others as well, as you go through the training. If you are unwilling to experience such emotions, then we recommend that you not participate in the training program until you are ready and willing. 

16b.) Please be aware your Biocybernaut experience may involve the reliving of many memories, including some childhood memories. Because of the nature of the development of the human consciousness, from childhood to adulthood, these childhood memories may be less than perfectly reliable. A useful example on this subject is given by Ken Wilbur, who is considered by many to be one of the most comprehensive philosophical thinkers of our time: 

If you take children in the preoperational state, and—right in front of their eyes—pour water from a short glass into a tall glass, and ask them which glass has more water, they will always say the tall glass has more. They cannot ‘conserve volume’. Certain ‘obvious’ things that we see, they do not and cannot see—they live in a different worldspace. If after concrete operational awareness (the stage after pre-operational awareness) has emerged, you repeat this experiment, the kids will always say that both glasses have the same amount of water. They can hold volume in their mind. If you show them a videotape from the earlier period, they will deny it’s them. They simply cannot imagine somebody being so stupid as to think the tall glass has more water. So they underwent this massive paradigm shift, and not a bit of it remains in awareness. The self . . .completely rewrites its history from within the new and higher paradigm. So we are automatically (and subconsciously) ‘retro-reading’ our entire life from the perspective of a recently emerged worldview, and imagining all of this stuff was present from the start! Needless to say, this considerably distorts what was actually occurring in the earlier periods. Memory is the last thing you can depend on to ‘report’ childhood. 

A Brief History Of Everything, Ken Wilber 

17.) In the process of the training you may be asked to look at, and to honestly evaluate, your own responsibility for events in your past and to forgive yourself and to forgive others for things that you or others did or failed to do. If you are unwilling to take some personal responsibility for your past experiences and if you are unwilling to do the forgiveness work of the training, then we recommend that you not participate in the training program until you are ready and willing. 

18.) In order to benefit from the training you must have your own clear intention to participate as fully as possible in the processes of the training. If you were pushed by someone else to do the training and/or you really do not want to do the training and/or if you are unwilling to participate as fully as you can in the processes of the training, then we recommend that you not participate in the training program until you, yourself, are ready and willing. 

19.) During the training time in your private feedback chamber, you will need to sit upright and remain relatively still for extended periods of time. We do have available comfortable, well-padded armchairs that can be adjusted up and down, and which swivel to maximize your comfort and good posture. We also have available adjustable footrests to maximize your personal comfort and good posture. If you have any medical, physical, or psychological condition that makes it difficult or impossible to sit upright and to sit still in this helpful way, we recommend that you speak to one of the Biocybernaut Institute Trainers prior to participating in the Brain Wave Training Program. 

20.) More time is spent outside the feedback chambers than inside the chambers. After your time in the chamber, you will be asked to describe your

your Trainer, who will ask you many questions about your experiences in a through videotaped debriefing. Your Trainer will then provide you with helpful personalized coaching. You will be invited to recline on fluffy pillows on your own comfortable and cozy canopied single bed for these debriefings. The daily depth interviews are also conducted outside of the chambers. Also occurring outside the chambers are the very thorough data reviews and interpretations of your results, as well as meal times, and times for putting on the electrodes and watching videos and for asking questions. Most people choose to sit during these other activities outside of the feedback chambers, but sitting is NOT necessary if that would be uncomfortable for you. You may stand, kneel, or lie down for many of the other activities of the Alpha One Training. Much of the work that is done outside the chamber is amenable to reclining, and some people choose to go back and forth between sitting in comfortable chairs, lying on the floor on pads with pillows, lying in bean bag chairs, lying on canopied beds with blankets and pillows, and also kneeling and standing. 

21.) Drugs and medications can artificially affect your alertness and level of arousal, thereby making it harder to gain skill in brain wave feedback. Drugs and medications may also predispose you to certain potentially dangerous physiological reactions. We recommend that you DO NOT TAKE drugs, alcohol, or medications of any kind while participating in this program. However, DO NOT STOP taking any medications which have been prescribed by a physician, or drugs you are dependent upon for your health and well being. However, if you are taking any drugs or medications, please inform your Trainer so that we can determine how best to support your participation at this time. You are specifically requested not to use alcohol, nicotine, or caffeine either the day and night before, or at any time day or night during your training. Recall that caffeine is contained in some cold pills, some pain pills, in chocolate, in many teas (except herb teas), and even in many decaffeinated coffees. Heavy caffeine users may require 1-2 weeks of gradual withdrawal prior to their training, because caffeine addiction often causes headaches upon withdrawal. Caffeine is an addictive drug that causes anxiety and affects your level of arousal, making it harder to learn to control your own brain waves. 

Are you currently taking any drugs or medications?

If you answered “Yes” just above in question 20.), please list ALL the drugs and medications you are currently taking (both prescription and non-prescription), and theconditions for which you are taking them. Use the space below and the back of this sheet if necessary. { List of drugs and medications: } 

 

22.) If you experience very severe premenstrual syndrome, we recommend that you consider not scheduling your training during that time. Levels of alpha EEG are lower during the premenstrual week, as is typical when anyone is under stress. We have found that the optimum levels of alpha, as well as optimum levels of learning of self-control of EEG, may not be achieved during the premenstrual week if you experience very severe premenstrual syndrome. If you have any questions, we recommend you speak with a Biocybernaut Institute Trainer. 

23.) Please read the following carefully and thoughtfully and then initial each item. 

A.) I understand and acknowledge that Biocybernaut training does not do anything to me. It only provides me with information about myself (feedback) and gives me the opportunity to learn about myself (education) and how to self-regulate processes in my brain, mind, and body. This learning requires my active involvement.

 B.) I understand and agree that the Biocybernaut training is an educational tool that I can use with my own ongoing efforts and understanding, to better my life and, further, that without my personal efforts and understanding it will have no effect.

 C.) I understand and agree that the Trainers and the technology are there for my education to help me understand myself better and to learn to function better in my life. I also agree that they are in no way responsible for the steps that I must personally take to effect the changes required to achieve the results I desire.

 D.) I understand and agree that the technology and the Trainers cannot “do” anything to me. The technology only provides feedback and the Trainers only provide education coaching, feedback, and guidance, which I must then act upon to produce the results I am seeking. 

 E.) I understand and agree that I am responsible for producing the results I seek in my Biocybernaut training.

 F.) I understand and agree that if I choose not to do certain portions of the training, or choose to withhold myself from applying myself honestly to the fullest of my abilities, I will be preventing myself from getting the greatest possible gains from the education available in the training.

 

24.) I have read this entire Informed Consent agreement and I fully understand it. I have given honest, truthful, and complete answers to all the questions, and I am not concealing or withholding information about my motives, history, or condition. I understand that the Biocybernaut Institute Brain Wave Training is not a substitute for the care of a professional psychotherapist or a medical doctor. I understand and agree that I am responsible for my own well-being and that the Biocybernaut Institute of Arizona, LLC. is only responsible for an orderly presentation of the training. I hereby agree to hold Biocybernaut Institute of Arizona, its owners, its managers and directors, its Trainers, its employees, its subsidiaries, its affiliates and its agents harmless from any and all liability arising in any way out of my participation in the training.

***If you are under 18 years of age, your parent or legal guardian must read, print, and sign below*** 

As the parent or legal guardian of the above named minor, I hereby give my permission for his/her participation in the program and I agree to the above Informed Consent on his/her behalf. I have read and agreed with all the above terms and conditions, and I certify the accuracy of all the answers to all the questions in this Informed Consent Agreement. 

Signature___________________________________________________Date __________ 

Parent(s) or legal Guardian(s) 

BIOCYBERNAUT INSTITUTE 1988- 2020 

Leave this empty:

Signature Certificate
Document name: Biocybernaut Confidential Information Form
Unique Document ID: de40d9a4c0a61278547388786e5df4d67ec0b4b9
Timestamp Audit
February 13, 2020 12:02 pm MSTBiocybernaut Confidential Information Form Uploaded by Kate O'Connor - kate@biocybernaut.com IP 24.121.25.178
February 13, 2020 12:04 pm MSTKate O'Connor - kate@biocybernaut.com added by Brian Alcorn - brian@biocybernaut.com as a CC'd Recipient Ip: 24.121.25.178
February 13, 2020 12:05 pm MSTKate O'Connor - kate@biocybernaut.com added by Brian Alcorn - brian@biocybernaut.com as a CC'd Recipient Ip: 24.121.25.178
February 13, 2020 12:37 pm MSTKate O'Connor - kate@biocybernaut.com added by Brian Alcorn - brian@biocybernaut.com as a CC'd Recipient Ip: 24.121.25.178
February 14, 2020 2:28 am MSTKate O'Connor - kate@biocybernaut.com added by Brian Alcorn - brian@biocybernaut.com as a CC'd Recipient Ip: 24.121.25.178
February 14, 2020 2:32 am MSTKate O'Connor - kate@biocybernaut.com added by Brian Alcorn - brian@biocybernaut.com as a CC'd Recipient Ip: 24.121.25.178
February 18, 2020 4:39 pm MST Document owner brian@biocybernaut.com has handed over this document to kate@biocybernaut.com 2020-02-18 16:39:56 - 24.121.25.178
February 18, 2020 4:39 pm MSTKate O'Connor - kate@biocybernaut.com added by Kate O'Connor - kate@biocybernaut.com as a CC'd Recipient Ip: 24.121.25.178
February 18, 2020 4:59 pm MSTKate O'Connor - kate@biocybernaut.com added by Kate O'Connor - kate@biocybernaut.com as a CC'd Recipient Ip: 24.121.25.178