Sign up for a 15-minute free consultation
MAGIS Therapies and Mindworks Neurofeedback Center is currently offering 15-minute free online consultations for those who need support and/or would like the opportunity to try Neurofeedback / Brain Mapping.

For questions and/or clarifications, you may contact our team at:
magis.mindworks@gmail.com

To help us serve you in the best way possible, please provide the information below.

Please note that this is not a 24/7 hotline.
In case of emergency, or if you think your life or someone else's life is in danger, please call:
DOH-NCMH Hotline:
0917-899-USAP (8727)
0917-989-USAP (8727)
Or go to the nearest hospital within your vicinity.

All information provided is kept strictly confidential.

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Adreça electrònica *
First Name *
Last Name *
Nickname *
Age *
Date of birth *
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/
MM
/
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Gender *
Civil status *
Complete address *
Email address *
Contact number *
Description of the problem or general concern *
You may be as detailed as you wish. Kindly note as well if you have been given a diagnosis and when have you been diagnosed by a developmental pediatrician or a psychiatrist.
Are you aware of what could be triggering your concern? *
Please write what triggers your concern and/or when does it happen.
How long has this been a problem for you? *
Please write when did you think your concern has started and how long has it been an issue for you.
How often does your concern takes place? *
If the frequency doesn't match with the choices below, you may be as detailed as you wish by choosing "other".
Have you sought therapy before? *
Please write the interventions you did in the past.
Are you taking any medications for your concern? *
Please enumerate the medications you are taking as of the moment, if there is any.
Is it your first time to seek Neurofeedback / Brain Mapping? *
How did you learn about Neurofeedback? *
IN CASE OF EMERGENCY, PLEASE CONTACT:
To support you to the best of our capacity, please include an emergency contact.
Full name of emergency contact *
Emergency Contact's complete address *
Emergency Contact's contact number/s *
Emergency Contact's relationship to you *
ACKNOWLEDGEMENT
I certify that the information provided in this form is true. *
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