QEEG Client Intake · Rose Institute

Section 01

Patient Information

Confidential · Please complete all fields

Personal Details

First Name *

Last Name *

Date of Birth *

Handedness

Gender Identity

Contact

Email Address *

Phone *

Preferred Contact

Home Address

How did you hear about Rose Institute?

Emergency Contact

Emergency Contact Name

Relationship

Emergency Contact Phone

Section 02

Health History

All information is protected health information handled in full HIPAA compliance

Current Medications

Include prescription, over-the-counter, and supplements from the past 30 days.

Medication Name	Dosage	Frequency

Clinical History

Past & Present Diagnoses

Symptoms & Concerns

Past Psychiatric Medication Response

Brief History

Section 03

Symptom Screening

Over the last 2 weeks, how often have you been bothered by any of the following?

	Not at all	Several days	More than half	Nearly every day

If you are in crisis or need immediate support, please call or text 988 (Suicide & Crisis Lifeline) or contact a trusted person in your life.

Section 04

Day-of Scan & Program

To be completed on the day of your appointment

Day-of-Scan Information

The accuracy of your QEEG results depends on your brain state at the time of the scan. Please avoid caffeine, cannabis, alcohol, and stimulants on the day of your scan.

Were any medications taken within 48 hours of this appointment?

Medication details (if yes)

Did you consume any stimulants today? (caffeine, soda, cannabis, alcohol)

Stimulant details (if yes)

Is RUSH processing requested for your report?

Program Selection

Select the program tier you are enrolling in. All tiers include two appointments with Dr. Mary Rose and a written report.

Tier One · Insight

$3,750 · One-time

Two appointments + QEEG brain scan + written report + personalized recommendations. Best for first-time clients.

Tier Two · Precision

$7,500 · One-time

Everything in Tier One plus deeper interpretation and concierge-level assessment. In-home or on-location available.

Tier Three · Continuum

$15,000 · Annual

Two comprehensive assessments per year with side-by-side comparison. Ongoing coordination and continuity of care.

Tier Four · Premier

$60,000 · Annual

Full brain health partnership. Limited availability. $40,000 per additional household member.

Section 05

Consent & Agreement

Please read each section and confirm your agreement below

Acknowledgments

I consent to the QEEG brain mapping procedure as described above and understand it is not a medical diagnosis. I have read and agree to the 48-hour cancellation policy. I understand late cancellations may be charged the full fee. I agree to the financial terms and authorize Rose Institute to charge the agreed program investment on the day of Appointment 1. I acknowledge receipt of the Notice of Privacy Practices and understand how my health information may be used.

Signature

Full Legal Name *

Today's Date

By typing your name above and checking all boxes, you are providing your electronic signature and agreement to the terms of this document.

✦

Thank you.

Your intake packet is complete. Dr. Mary Rose and the Rose Institute team will review your information before your first appointment.

Questions? Contact us at 303.850.2695 or connect@theroseinsitute.org

"Every brain is singular. Every plan is built around yours."
— Dr. Mary Rose, Founder