Consent for Virtual reality Therapy

Virtual Reality Exposure Therapy is extremely safe for the general population. A small percentage of the population may experience motion sickness (nausea, vomiting, ataxia, disorientation, eye strain and vertigo) due to “sensory cue incongruity”. That is due to differences between what they are perceiving in the virtual environment being different from what their body is experiencing. However, it should be noted that improvements in the lag time between the virtual images and head movements have reduced these side effects for many people.

There are some issues and disorders that are contraindicated for this type of procedure (see below for contraindications). Please read through the following list of medical conditions. Please answer “yes” or “no” for each item. If you’ve been diagnosed with or believe you suffer from any of the following medical conditions,please inform Dr. Howard Gurr.

Clients diagnosed with any of the following conditions are contraindicated and therefore should NOT use Virtual Reality Therapy.

__An infectious disease

__Severe Motion Sickness or Vertigo

__Extreme vison or hearing impairment

__Agitated Depression


__ Schizophrenia

__ Borderline Personality Disorder

__Unstable Dissociative Disorder

__Acute or Chronic Brain Syndromes

__Seizure Disorder



__Attempted Suicide


If you have any further questions, please ask Dr. Howard Gurr before indicating your acceptance by signing this consent form.


I have read, or had read to me, and understand the information provided to me by Dr. Howard Gurr

Signed: ________________________________________________

Date: _____/_____/_____