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Client Intake Form

PART 1: CLIENT PROFILE & INTAKE MATRIX

Do you have a history of cardiovascular disease, severe hypertension, or pacemakers?
YES
NO
Do you experience epilepsy, severe neurological seizures, or fainting episodes?
yes
no
Are you currently pregnant, or suspect you may be pregnant?
YES
NO
Do you suffer from Raynaud’s Disease, severe cold-hypersensitivity, or open wounds?
Yes
No
Are you currently undergoing treatment for any active, diagnosed clinical illness?
yes
no
You understand Brain Gym LLC is not a medical facility, we do not act as licensed medical professionals, doctors or mental health professionals.
No
Yes
You understand this is strictly non-diagnostic in nature. We do not screen for, detect, diagnose, treat, prevent, or cure any clinical disease, cognitive disorder, psychological defect, or physical illness.
YES
NO
You understand equipment utilized inside this facility are classified and deployed as General Wellness Equipment under the established guidelines of the U.S. Food and Drug Administration (FDA)
NO
YES
You release, waive, acquit, and forever discharge Brain Gym LLC, its managing members, officers, employees, independent contractors, agents, and landlords from any and all claims, demands, liabilities, causes of action, damages, costs, or expenses.
yes
no
Date
Month
Day
Year
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MANDATORY METABOLIC & PHYSICAL SCREENING
Please answer yes (Y) or no (N) to the following physical conditions to ensure a safe modality allocation:

  • Do you have a history of cardiovascular disease, severe hypertension, or pacemakers?
  • Do you experience epilepsy, severe neurological seizures, or fainting episodes?
  • Are you currently pregnant, or suspect you may be pregnant?
  • Do you suffer from Raynaud’s Disease, severe cold-hypersensitivity, or open wounds?
  • Are you currently undergoing treatment for any active, diagnosed clinical illness?

PART 2: NON-DIAGNOSTIC DISCLOSURE & FDA ALIGNMENT

Brain Gym LLC offers cutting-edge neuro-harmonization, cellular optimization, and recovery coaching modalities. Brain Gym LLC is explicitly not a medical clinic, medical facility, or psychiatric treatment office. Staff and facilitators operating within this building are wellness operators and recovery technicians; they do not act as licensed medical professionals, doctors, or clinical therapists.

The services, scans, tracking loops, and instructional processes conducted at Brain Gym—including but not limited to Neurofeedback and Psych-K® alignment—are strictly non-diagnostic in nature. They do not screen for, detect, diagnose, treat, prevent, or cure any clinical disease, cognitive disorder, psychological defect, or physical illness. Clients are advised to seek direct guidance from a primary care physician before beginning any advanced metabolic or physical conditioning protocols.

The Vasper Vitality Systems and Photobiomodulation (Red Light) equipment utilized inside this facility are classified and deployed as General Wellness Equipment under the established guidelines of the U.S. Food and Drug Administration (FDA). These systems utilize low-impact compression, thermal regulation, and targeted wavelengths to optimize athletic recovery, cellular energy production, and physical conditioning. They do not constitute restricted, prescriptive medical devices. Neurofeedback EEG hardware operates strictly as an educational biofeedback mirror to train the central nervous system in self-regulation and focus enhancement.

PART 3: PERSONAL OUTCOME RESPONSIBILITY & CANCELLATION POLICY

By enrolling in services at Brain Gym LLC, the client explicitly acknowledges and agrees that they are fully responsible for their own personal outcomes, progression, and transformation. Brain Gym LLC provides advanced optimization tools, modalities, and supportive protocols, but individual results depend entirely on the client’s personal commitment, biology, and consistent participation.

Furthermore, out of respect for our operators and scheduling flow, missed appointments or late cancellations will be charged at the full service rate unless a formal cancellation or rescheduling notice is provided at least 48 hours prior to the scheduled session time.

PART 4: RELEASE OF LIABILITY, INDEMNIFICATION, AND HOLD HARMLESS

  • Assumption of Risk: The client acknowledges that participating in advanced physical and cognitive modalities—including vascular compression (Vasper), systemic photobiomodulation (Red Light Therapy), deliberate exposure to extreme cold (The Sacred Cold Plunge), and real-time brainwave tracking (Neurofeedback)—carries inherent physical and physiological risks. These risks include, but are not limited to: muscle strains, temporary dizziness, sudden changes in blood pressure, thermal shock, cardiac acceleration, and psychological shifts. The client freely, voluntarily, and explicitly assumes all risks, both known and unknown, associated with these wellness modalities.
  • Waiver & Release: The client, on behalf of themselves, their heirs, executors, and administrators, hereby releases, waives, acquits, and forever discharges Brain Gym LLC, its managing members, officers, employees, independent contractors, agents, and landlords from any and all claims, demands, liabilities, causes of action, damages, costs, or expenses (including legal fees) arising out of or related to any physical injury, psychological distress, property loss, or medical event sustained while inside the facility located at 822 Forest Drive N, Riverton, WY, or during the execution of any recommended optimization protocol.
  • Indemnification: The client agrees to indemnify and hold harmless Brain Gym LLC against any claims or legal actions brought by third parties (including the client's family members or insurance providers) resulting from the client's participation in Brain Gym LLC programs or use of its technical hardware.
  • Governing Law: This agreement shall be governed, construed, and enforced in accordance with the laws of the State of Wyoming. Any legal action, dispute resolution, or arbitration arising directly from this contract shall be executed exclusively within the courts of Fremont County, Wyoming.

5. Mandatory Sanitation Rules:

To maintain an optimal, ultra-sanitized environment and safeguard the health of all members, the client agrees to adhere strictly to the following facility hygiene protocols prior to entering the cold plunge water basin:

  • Mandatory Rinsing Shower: The client must thoroughly rinse off all body oils, perfumes, heavy deodorants, self-tanning products, and lotions in the facility shower using fresh water immediately prior to stepping into the cold plunge.
  • Clean Athletic Attire: Proper, clean swimwear or synthetic athletic apparel is strictly required. Cotton fabrics, streetwear, or clothes worn during a prior workout session are completely prohibited.
  • Bio-Contaminant Restrictions: The client affirms they have no open wounds, unhealed abrasions, active skin infections, or communicable illnesses.
  • Violation Policy: Failure to adhere to these sanitation benchmarks introduces chemical contamination that compromises our multi-stage filtration systems. Brain Gym LLC reserves the right to immediately terminate the session, assess a $200 deep-cleaning maintenance fee if a system flush is triggered, or revoke facility membership without a refund.

PART 6: BINDING ACKNOWLEDGMENT & SIGNATURE

BY SIGNING BELOW, I AFFIRM THAT I HAVE READ THIS ENTIRE DOCUMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I AM GIVING UP SUBSTANTIAL LEGAL RIGHTS BY SIGNING IT, AND EXECUTE IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT OR COERCION.

Client Printed Name: __________________________________________________
Client Signature:_______________________________________________________
Date: ____ / ____ / ______

To ensure strict commercial compliance, maintain pristine water chemistry, and protect your filtration equipment at 822 Forest Drive N, a dedicated sanitation block has been injected into your onboarding document.

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