Effortless Pain Resolution Intake Form

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

What is your annual income?*

Are you the sole financial decision maker in your household or do you share decision making with your partner/spouse?

Sole Financial Decision MakerShared Financial Responsibility

Does any of the following pertain to you:*

Please list below the injuries or conditions that pertain to you. What is the number one area of concern you wish to work on?:*

What activities are you interested in doing but cannot any longer because of this issue?

What have you done so far to manage or control your symptoms?

This program is hands down the best life-changing pain resolution option that is completely natural and results in new permanent changes that benefit you in many ways. It does require some of your time (about 2 hours a day), and the good news is you do it on your own time. Are you able to commit at least 2 hours a day to the program if it results in getting your life back without surgeries or meds?

YESNO

After you submit your application, I will review it and see if you are a good fit for Neurotherapy. If so, I will send you an email with a link to book a call to further discuss the program. I look forward to speaking with you soon!