Neural Wellness Application

Name

First

Last

Email

Phone Number

City, State, Zip Code

Date of Birth

Health Concerns - Which of the following do you need support with? Check ALL that apply.

Brain & Nervous System Support
Mental Health & Emotional Wellness
Chronic Pain & Inflammation
Detox & Cellular Restoration
Hormone Imbalance & Endocrine Support
Autism & Developmental Support
Anti-Aging & Skin Rejuvenation
Immune System Support
Weight Management & Metabolic Health
Addiction & Dependency Recovery
Cognitive Decline & Memory Support
Long COVID & Post Viral Recovery
Lyme Disease & Complex Infections
Mold & Environmental Toxin Exposure
Gut Health & Digestive Issues
Sleep Disorders & Insomnia
PTSD & Trauma Recovery
Not Sure — Need Guidance

Dependencies

Amphetamines, Meth, Cocaine & Stimulants
Heroin, Opiates, Morph, Subox, Meth & Tobacco
Pain Killers, Marijuana, Alcohol & Benzos
Barbiturates, Sedatives & Tranquilizers
Pornography, Gaming, Gambling & Sexual

Physical

Memory Enchancement, Focus, Concentration
Insomnia, Sleep Apnea, Fibromyalgia, Chronic Fatigue, Chronic Pain
Headaches, Migraine, Sinus
Weight Control, Hormone Balance
Autism, Alzheimers, Parkinson's Disease
Muscular Dystrophy, Multiple Sclerosis

Emotional

Is there anything else not listed above that you'd like support with?

Health History - Please list any current medications and supplements

Health Diagnosis - Please share any relevant medical history, diagnoses, or conditions

Pregnancy Status

I am not pregnant
I am pregnant
I am breastfeeding

Do you have a pacemaker or any implanted electrical device?

Do you have a history of seizures or epilepsy?

Do you have any implants of any kind?

What type of service are you interested in?

In-Home Sessions
Virtual Sessions
Program Enrollment
Not Sure Yet

What is your main health goal?

Have you tried other treatments or approaches? If, so please explain below.

How soon are you looking to see results?

Immediately - I need help now.
Within 1 month
Within 3 monthss
I understand healing takes time and I am committed to the process

so Physical Status

How did you hear about us?

What days are you generally available?

What time of day works best for you?

Morning 8am-12pm
Afternoon 12pm-4pm
Evening 4pm-7pm
Flexible - Any Time

What's your investment range for wellness support? Healing is an investment in your future. Understanding your budget helps us design a protocol that works for your situation.

Are you ready to commit to showing up consistently?

Are you ready to commit to a multi-session protocol (minimum 6-8 weeks)?

Yes, I'm ready to invest in this!
I need more information first.
Not right now.

Is thre anything else you would like us to know before your consultation?