Name *

First Name

Last Name

What conditions do you experience?

Check all that apply

ADD / ADHD

Addiction

Anxiety

Depression

Chronic Fatigue

Chronic Pain

TBI or Concussion

Eating Disorder

Epilepsy

Fibromyalgia

Headache | Migranes

Sleep issues | Insomnia

Learning Disorders

Memory Disorder

Dimentia

Alzheimer's

Stroke

OCD

Abuse (Physical, Emotional or Spiritual)

Suicidal Thoughts / Dark Thoughts

Self Harm

Academic Performance / Focus Issues

Spiritual Attack

Racing Thoughts

Trouble Forgiving Others

Trouble Forgiving Myself

Trouble making friends or finding authentic relationships

Feeling Lost | Trying to figure out my path and purpose

Other

What services are you interested in?

Check all that apply

MCN + Microcurrent Neurofeedback

RET + Rapid Eye Technology

Trauma Resolution Coaching

Brain Tap Training

MAP Method Coaching (coming soon)

Deliverance & Inner Healing (please fill out the deliverance application in the menu)