IASIS Micro Current Neurofeedback (MCN) Inquiry Form

IASIS Micro Current Neurofeedback (MCN) Inquiry Form

Complete this form and our administrative team will be in touch about next steps to receive IASIS MCN Treatment at Aspen Haus Associates, LLC.
Client Information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Contact Information

If the client is a minor, please provide the contact information for the minor's guardian.
PLEASE NOTE: We will not contact an adult on behalf of another adult unless there are documented and legal arrangements for power to do so.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
IASIS MCN Treatment Interest

Please check all that apply.
Reasons for seeking treatment:

InsomniaMemory ChallengesLyme DiseaseMemory DisordersMigrainesPsychological DisordersPTSD & Trauma SymptomsStrokeTraumatic Brain Injury (TBI)ADD/ADHD SymptomsEmotional RegulationAnxietyUp-regulated Nervous SystemChronic Fatigue SyndromeSleep DisturbancesDepressionEpilepsyStress ManagementFibromyalgiaHeadachesPeak PerformanceOther
Referral Program

We have a generous referral program. If someone referred you to IASIS, please provide their first and last name below so we can give them their referral reward.
Person that referred you to AHA for IASIS MCN:
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By submitting this form, you are agreeing to and permitting the team at Aspen Haus Associates, LLC to contact you using the information you have provided.
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IASIS Micro Current Neurofeedback (MCN) Inquiry Form

Client Information

Contact Information

IASIS MCN Treatment Interest

Referral Program

Submit