Liability Form

ThetaPod Services Informed Consent and Waiver

The ThetaPod is designed to induce a person's brainwave activity into a wavelength scientifically referred to as "theta state." While in theta, the brain waves can be measured at 4-8Hz. In comparison, when we are busy concentrating in gamma state, our brains are operating at 35-100Hz. Theta is a state of relaxation that is well known for the drowsy, abstract sensation we experience as we are falling asleep. You may have little to no concept of time while in theta, and you may feel like you’ve “zoned out” while in the ThetaPod.

Helping you go into theta allows your brain to take the majority of its focus off of sensory perception and conscious thought so that therapies are much more effective.

Vestibular Motion is the spinning of the ThetaPod. It throws off the brain's natural sense of time and space, and people feel like they're floating or rocking. You will be able to sense the ThetaPod movement as it starts and stops the session, but once it reaches constant speed after the first rotation, you will not be able to sense the spinning.

The important thing here is that these movements are purposely enhancing the flow in your biomagnetic field and therefore stimulating your brain. There are many ways to do this, but the idea is that using your physiology we can enhance and manipulate the flow in the biomagnetic field, the place where thoughts and emotions reside. Vestibular motion has also been found to be an important component in brain development, which is why young children intuitively love to spin.

Cranial Electrotherapy Stimulation (CES) is delivered through the clips we put on your ears. Studies have shown that the deep relaxation and calm alertness produced by CES increases suggestibility along with an induced state of openness and heightened awareness. CES is a common modality utilized in the recovery of drug addiction. It is just as effective with other self-destructive/behavioral challenges such as anxiety, depression, etc.

You may get new ideas, have old memories come up, or experience other subconscious material come into your awareness. If anything comes up that you would like to process in a coaching session with April, or if you would like to work on it with a therapist or other specialist, let us know and we can help you get the support you need.

We will adjust the CES clips so that the current is just below where you can feel it. The current does increase and decrease in intensity during a ThetaPod session. The most sensation you will feel is a slight tingling in one or both earlobes.

Binaural Beats are used to bring the brain into a theta state. Slightly offset tones are played through headphones, which means that you will hear different tones in each ear, and the brain works to synchronize them. The effect of binaural beats on brainwaves depends on the difference in frequencies between the two tones. For example, if 400 Hz was played in one ear and 410 in the other, then the binaural beat would have a frequency of 10 Hz.

Your brain is separated into two distinct cerebral hemispheres. As these two sections of your brain work together to synchronize the tones, it has the effect of calming and balancing the activity in the brain. This therapy can also correct conditions for neural pathway re-establishment, also known as "entrainment." The immediate result is deep relaxation during treatment, and the lasting effects can include building healthy new neural pathways.

Visual Pattern Light Stimulation is delivered through the goggles we will place on your closed eyes. This modality is one of the most interesting as the ThetaPod will only emit pulsing white light, yet your brain will interpret the light into a variety of colors and patterns. This experience is different for each person and usually changes when running different programs and at different light intensities.

The light stimulation is computer-generated and calibrated to synchronize with the binaural beats. The effects are that it (1) quickly induces theta state, (2) opens the brain to suggestion and entrainment, and (3) promotes specific beneficial rhythms in the brain. The ThetaPod uses computer technology to precisely generate and synchronize these lights for maximum positive effects to:

  • stimulate healthy production of neurotransmitters like serotonin and dopamine

  • reduce cravings

  • elevate mood

  • enhance well being

  • encourage greater self-control


If you have any of the following conditions, please let us know and consult with your physician before starting sessions in the ThetaPod:

  • Pacemaker
  • Internal defibrillator
  • Internal insulin pump
  • Prone to seizures
  • Light sensitivity, such as to strobe lights

Do not get into the ThetaPod if you are under the influence of alcohol or drugs, and let your technician know if you are taking any medications.

It is important not to move or try to sit up while in the ThetaPod. Lifting your head during a session can make you very dizzy. Your technician will show you how to stop the session at any time if you need to do so.

We do not make any medical claims of healing or cures. With more than 30 years of research, compromising hundreds of studies and first-hand patient outcomes, these ThetaPod treatment protocols have been shown to be safe and effective.

I have read the above disclosures and voluntarily agree to the terms of use. I thus give permission for Align Theta Center staff to assist me in sessions in the ThetaPod. I give the technicians full permission to put the CES ear clips on my ears, headphones on my head, and light goggles resting on my eyes. I understand that I will be able to stop a ThetaPod session at any time.

Consent for Treatment at Align Theta Center

I acknowledge that I have received, have read (or have had read to me), and understand the information about the therapy I am considering. I have had all my questions answered fully.

I do hereby seek and consent to take part in the recovery-oriented system of care provided by this center, its contractors, and/or its employees. I understand that developing a treatment plan and regularly reviewing the work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process.

I understand that I must call to cancel an appointment at least 24 hours before the time of the appointment. If I do not cancel or do not show up, I will be charged for that appointment. The staff at Align Theta Center will work with me to reschedule appointments as availability allows but can make no guarantee that requested changes can be accommodated.

I understand that no promises have been made to me as to the results of alternative health treatment, coaching, case management, supportive services, mentoring, or of any other procedures provided by this center, its contractors, and/or employees.

I am aware that I may stop any course of treatment at any time. If I do decide to discontinue services, the only thing I will still be responsible for is paying for the services I have already received and for missed appointments that I have not cancelled within 24 hours in advance.

My signature below shows that I understand and agree with all of these statements.

Signature of Client (or person acting for client): _____________________________________

Printed Name: ________________________ Relationship to Client: ____________________

Date: _____________________________

I, the Align Theta Center representative, have discussed the issues above with the client (and/or his or her parent, guardian, or other representative). My observations of this person's behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent.

Align Representative: _______________________________. Date _________________________

Client Information and Release

Please read and sign the following statement, which is a waiver of certain rights:

1. I hereby apply for treatment at Align Theta Center. I agree to receive neurological, detoxification, electro stimulation, nutrition, and other forms of therapy from Align. By signing below, I affirm that all information I have provided to Align is true, correct, and complete. I agree to keep Align staff informed of any changes in my health prior to receiving any treatment session.

2. I understand that Align's treatments are not a substitute for medical treatments, medical advice, or medications that are provided by or recommended by my personal physician or other health care provider. I am aware that it is beyond Align's scope of practice to diagnose illness or disease or provide medications. Also, because some of the services provided by Align may be harmful under certain medical conditions, I affirm that I have truthfully and fully stated all my known medical conditions and medical history.

3. I understand and am aware that under certain conditions, it is possible that flashing lights may cause a seizure. I hereby consent to Align's use of flashing lights in my treatment. I understand that I may choose at any time to receive treatment that does not include flashing lights. I further understand that sudden withdrawals from alcohol and benzodiazepines as well as other drugs can cause serious health risks and even death. I hereby release Align Theta Center, its members, managers, officers, affiliates, employees, agents, and any and all of its associates or staff (the "Released Parties") from any and all liability relating to treatments or my relationship with Align. I agree that if any part of any treatment makes me feel uncomfortable at any time, I will immediately inform the Align staff. I understand I have the right to stop a treatment session at any time for any reason.

4. I agree to keep Align and my personal physician or health care provider updated as to any changes in my medical condition and understand that Align shall not be held liable for my failure to do so. I understand that failure to comply with instructions from Align staff will be grounds for Align to immediately stop my session.

5. I understand that while services provided by Align are intended to enhance relaxation, improve circulation, assist in detoxification, improve emotional function, help restore functional neurology and brain chemistry, and offer an overall positive experience, Align does not guaranty the results of any of its treatments.

6. By signing this form, I, for myself and for my heirs, next of kin, assigns, and personal representatives, hereby agree to and do release, indemnify, and hold harmless Align Theta Center and the Released Parties from any and all injuries and damage that I, or the person upon whose behalf I am signing, may sustain or incur arising out of or related to treatments I receive from Align or my relationship with Align Theta Center. I, for myself and for my heirs, next of kin, assigns, personal representatives, and persons upon whose behalf I am signing, hereby agree to and do release, indemnify, and hold harmless Align Theta Center and the Released Parties from any and all causes of action, claims for damages, or demands whatsoever. MY WAIVER GRANTED HEREIN IS BINDING EVEN IF ALIGN THETA CENTER OR THE RELEASED PARTIES HAVE CAUSED OR CONTRIBUTED TO ANY DAMAGE OR INJURY THROUGH THEIR COLLECTIVE OR INDIVIDUAL NEGLIGENCE.

Client Information and Release Continued

Signature of Client (or person acting for client): _____________________________________

Printed Name: ________________________ Relationship to Client: ____________________

Date: _____________________________


Security of your personal information is of paramount importance to our continuing business and successful relationships with our clients. All written or oral information and materials disclosed or provided by our clients to Align Theta Center will be kept in strict confidence and will not be used for purposes other than providing treatment without the client's written permission.