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Request for Biofeedback Sessions

Print out the following form:

The Professional Biofeedback Program at SSU offers biofeedback training to Students, Faculty, and the Community. Our trainers are enrolled in the in the practicum or internship section of the professional Biofeedback Training Sequence. This is an excellent opportunity for you to be introduced to biofeedback with trainers under the supervision of leaders in the biofeedback community. Sign ups begin in the beginning Fall (late August) and Spring (late January) semesters. *We recommend that you that you sign as soon as possible due to sometimes heavy participation in the program.*

Please complete the following information.

Name__________________________________ Date___________________________

Phones: (Day)__________________ (Eve)______________ E-mail______________________

The following information is important so that we can match you with the right trainer

[ ] Psych 454 Student [ ] Student at large [ } Community resident [ ] Staff/Faculty at SSU

[ ] Credit for another class (which one) _________________________

Have you had previous biofeedback experience? Y / N

When/ With Whom/ Where ________________________

Indicate your goals as a trainee:

[ ] Learn relaxation techniques [ ] Interest in becoming a trainer

[ ] Address Physical Ailment __________________________________________________

[Other] ____________________________________________________________________

Please indicate with an X the hours that you are available. Sessions begin on the hour and last about 50 minutes. A commitment of 8- 10 sessions is recommended in order to gain the skills needed for self regulation. Due to many requests, We can only call those that we can accommodate. IF you do not receive a call, you will be put on the waiting list. If you have not been called and you are interested in the following semester, we encourage that you re-apply.

Available Times Table:

Hour Monday Tuesday Wednesday Thursday Friday Saturday

Please return this form to the Biofeedback Mailbox located in the Psychology Department- Stevenson 3092.


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