Fill out the fields below to get your EEG Directory listing:
Instructions: fill out all applicable fields and hit "submit" at the end of the page to send your data to the EEG Directory database.
If you have questions, please feel free to call 877-334-7878 or 866-334-7878 for help.

Filling out this form usually takes about 10 minutes.

	required field = *
First Name	*
Middle
Last Name	*
Degree	select here... AA B.S. BSC BSN D.C. DDS D.O. LCSW M.A. M.D. M.Ed. M.S. MFT MSW R.N. Ph.D. Psy.D. Dipl. Dr. Prof.
Business Name or Institution
Street Number & Suite	*	(e.g. 461 Ocean Blvd. #214)
City	*
State	Select US state here...  -not applicable-  Alabama  Alaska  Arizona  Arkansas  California  Colorado  Connecticut  Delaware  District of Columbia  Florida  Georgia  Hawaii  Idaho  Illinois  Indiana  Iowa  Kansas  Kentucky  Louisiana  Maine  Maryland  Massachusetts  Michigan  Minnesota  Mississippi  Missouri  Montana  Nebraska  Nevada  New Hampshire  New Jersey  New Mexico  New York  North Carolina  North Dakota  Ohio  Oklahoma  Oregon  Pennsylvania  Rhode Island  South Carolina  South Dakota  Tennessee  Texas  Utah  Vermont  Virginia Washington  West Virginia  Wisconsin  Wyoming
ZIP-code	*	or Postal code or Postleitzahl USA: 5 digits, e.g. 90210
Country	USA Canada Mexico Puerto Rico Belgium France Germany Italy Hungary Czech Republic Austria Switzerland Spain Portugal Malta Netherlands Norway Denmark Finland Sweden Poland Hungary Australia New Zealand Singapore Thailand Malaysia Philipines China Korea OTHER  *	If we missed your country, PLEASE email us at info@eegdirectory.com and we will enter your country ASAP. Select 'other' in the meantime.
Tel for public	*	(published in directory)
Tel for administration	*	(NOT published. If you don't have a 2nd one, enter first one here)
Fax		(e.g. (717) 123-4566 )
Email #1 - business address	*	(published in directory)
Email #2 - personal address	*	(NOT published. If you don't have a 2nd one, enter first one here)
Do you already have a website you would like to list?		(website is displayed with premier membership)
Neurofeedback specialities	Attention and learning problems Mood disorders Conduct and attachment disorders Headache Sleep disorders Brain injury and seizures Parkinson's and movement disorders Autism and developmental disorders Chronic pain Addictions Geriatric Peak performance
	Other:
License		e.g. BCIA, Licensed Professional Counselors (LPC) or Mental Health Counselor (LMHC), etc.
Certification
Practice speciality	*
Neurofeedback practice since	2008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966  *	(e.g. 1998)
Assessment	EEG CPT assessment     QIKtest using EEGexpert.com. T.O.V.A. assessment Quantitative EEG assessment Other:	(Click for a checkmark in the appropriate checkbox)
Medicare Provider	Yes	(Check if applicable)
Neurofeedback equipment	NeuroAmp Brainmaster BioExplorer NeuroCare Pro NeuroCybernetics Biograph / Infiniti BioIntegrator NeXus / Multi-Trace BrainQuiry / PET J&J HEG / pIR / nIR ROSHI Procomp LENS Other:
Mentor	Yes	Yes: promote our office to new clinicians as a source for consultation and mentoring

EEG Directory Services
Select your level of service here → BASIC ($150 initiation) $45 per month SUPPORT  LEVEL ($150 initiation) $95 per month PREMIER ($295 initiation) $195 per month INFORMATION LEVEL ($295 initiation) $75 per month INTER- NATIONAL 10EUR/$15 per month EEG Newsletters EEG Bulletin Board EEG Directory listing (simple) (highlighted + detailed )   EEG Associate Listserver     Group Phone Consultations with Susan Othmer, BCIAC (eligible for BCIA mentoring hours)     Weblink in EEG Directory listing       Web site   (standard style) (custom or your existing website)     EEG Support (1 hour)       Bulk Purchases       Free loaner amplifier (NeuroAmp, Brainmaster, Procomp)       Banner Ads         High quality printed brochures         Expanded search criteria         Promotional materials with your logo and info (for printing cost)         Funds go primarily to cooperative national advertising
Check here to become a CHARTER member: get 6 months of PREMIER service for $975 (regular price $1200)    Check here to add a $10 donation to the Brian Othmer Foundation to your membership: »www.brianothmerfoundation.org
(all figures and amounts are monthly)
How did you hear about EEG Directory?:	( Please select here from this pulldown list ... ) Seminar by Sue Othmer Seminar by Siegfried Othmer Reference on EEGinfo.com Reference on EEGexpert.com Reference on EEGsupport.com Recommendation by colleague List server mention Client Online article Online advertisement Search engine E-mail announcement Print advertisement Print magazine article Print newspaper article Advertisement in the mail Conference booth Other
Who may we thank for this referal?		Please enter e-mail address. Email addresses are strictly bound to EEG purposes and will never be used or rented out for spam
Would you like to point out this service to your collegues?:		Please enter e-mail address. Email addresses are strictly bound to EEG purposes and will never be used or rented out for spam
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Terms of Service
Cancellations are effective at the end of the billing cycle.

What happens after you submit:

A member of the EEG Directory team will verify your data and activate your account. You will be notified via the personal email address you entered. Billing information will be retrieved by phone and not via insecure internet. Your credit card information is stored separately from EEG Directory's internet servers.

Thank you,
the EEG Directory team