AIT PARTICIPATION AGREEMENT

 I agree to enroll ____________________________, in auditory integration therapy.

 I understand that the treatment involves two 30-minute listening sessions a day for ten days, plus additional sessions, as needed for testing.  I understand that if more than one week is missed during the 10-day set schedule, the program will have to begin again.

 I understand that if tubes are present in the ears, it may be best to wait until they come out before receiving the treatment and if an ear infection occurs, the treatment should be discontinued until the infection passes.

 I understand that headphones should not be worn for recreational purposes after receiving the treatment, as it may interfere with benefits from the retraining.

 I understand that headphones should not be worn for recreational purposes such as listening to loud music after receiving the treatment, as it may interfere with benefits from the retraining.  However, listening to BOOKS on TAPE is encouraged.

 I understand that there is no guarantee of positive results and that physical and/or behavioral problems may be experienced during or after the treatment sessions.  These may include, but may not be limited to, sleep and eating disturbances, headaches, nausea, fatigue, aggression, and tantrumming.  I agree to indemnify and hold Enhanced Auditory Retraining Service harmless for physical and/or behavioral problems, should they be experienced at any time during or after the participation in the treatment.

 All of the above has been discussed with me and agreed upon and I willing enroll in the program.

 Signature: _________________________ Telephone: _______________

Name: _____________________________________________________

Address: ___________________________________________________

City: ________________________________ State: ____ Zip: ________

Please return with $500 deposit to:

Saroj Madan, M.S., 22 Jennifer Road, Lowell, MA 01854

Upon receipt of this form and your deposit, questionnaires will be sent to you for completion and you will be contacted to schedule your appointments.