Cognitive Remediation Consent Form

Cognitive Remediation Consent Form

Cognitive Remediation Consent Form

Cognitive Remediation Consent Form

The completion of this Consent Form is MANDATORY before any Cognitive Remediation therapy can commence. There is to be no exemption to any part of the consent form.

The Consent Form is to be scanned and uploaded to the client’s medical file.

The following information is required to be read in its entirety, understood, acknowledged, and accepted, by the client seeking to undergo Cognitive Remediation (CR) therapy at The Shrink Neuro.

1. CR is a tailor-made cognitive training program which consists of several activities and exercises aimed at improving individuals’ cognitive and adaptive functioning.

2. Cognitive activities and parts of the program are performed both electronically and paper-based.

3. The majority of the cognitive activities will be performed during session, however at times there may be additional homework tasks to be completed outside of session hours.

4. CR is progressive, cognitive improvements will be slow and occur over a period of time. There are generally no observable changes in cognition after a limited number of sessions.

5. There is no guarantee that CR will be effective for every client, or, that there will be observable enhancements in cognition during or after a treatment course.

6. Participation in this treatment is voluntary. You are free to withdraw your consent and discontinue participation in the treatment at any time throughout the prescribed treatment period without negative consequences to your relationship with The Shrink Neuro.

7. CR should be an adjunct to a ­client’s treatment program and should be used in conjunction with: pharmacotherapy (medications), psychotherapy, and/or neurostimulation.

8. There is limited but growing evidence that CR enhances cognitive and daily functioning.

9. There is no guarantee that CR will be effective in improving cognitive or daily functioning.

10. CR may be administered by your treating clinician, or, another clinician trained and credentialed in the administration of CR.

Terms and Conditions of Service

Accounts that are to be settled by a 3rd party (e.g. DVA, WorkCover) require written pre-approval from the party. If pre-approvals are not obtained, the account will be the responsibility of the client.

Your adequate and complete informed consent is required to proceed with Cognitive Remediation

Client Full Name
Client Full Name
First
Last

Hereby acknowledge that I have:

a) Been given the TSN-FORM-CLIN-002 Client Information Sheet for CR (v1.0) and have read and understood it in its entirety
b) Read this Consent Form and all included information in its entirety
c) Understood this Consent Form and the Terms of Service
d) Have been given an opportunity to ask my treating psychologist questions about CR
e) Have been given the opportunity to make an informed decision along with my family and/or caregivers
f) Accept the Terms and Conditions of this procedure, including the Terms of Service
g) Been given a copy of the Cognitive Remediation Consent Form, and the Terms of Service

Name
Name
First
Last