Name *

First Name

Last Name

What conditions do you experience?

Check all that apply

ADD / ADHD

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 or Emotional)

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

Microcurrent Neurofeedback

LDDA | Rapid Eye

Coaching | Life, Empowerment, or Spiritual

Reiki

Sound Healing- Tuning Forks

Sound Healing- Drums

Sound Healing- Singing Bowls

Guided Meditation / Imagery Release

Sound Lounge - Vibroacoustic Sound Bed