How long have you been dealing with neurologic symptoms? What happened to cause them *

What types of issues have you been dealing with and what types of activities are these issues keeping you from doing? *

What have you tried so far to address these neurologic symptoms? *

Why do you think these efforts have been ineffective? *

Have you been dealing with migraine, severe headaches, or generalized head pain? *

Yes

No

We receive many applications and some applicants are more motivated than others. Are you a committed, highly motivated individual that is seriously ready to commit to a plan and will value the impact that a program and guidance from a neurologic rehab expert can have on your life? *

Yes, I am a serious applicant and am ready to commit to something that will provide results.

No, I'm still unsure of what I want to do.

What would make you "sure" of a path forward for your health that you would be willing to invest into? *

If we ended up figuring out a plan that got you symptom-free, are you currently employed and capable of investing into professional medical care? *

Yes

No

Age? (this can relate to different conditions and will help us prepare) *

<18

18-29

30-49

50+

Since you are under 18, you must have a parent or guardian present for this meeting. Please do not go any further unless you have confirmed with your parent/guardian that they can be present during the call, and are willing to financially support these health endeavors. *

Yes, I have confirmed with my parent/guardian

No, I have not confirmed with my parent/guardian yet regarding this meeting

Prior to booking this free consultation, we want to confirm that we are an online concussion program NOT a physical location, this consultation will be over zoom, and we provide 1:1 guidance to teach you how to fix your symptoms online. *

Yes, I understand this is an online process

No, I don't want help online, even if it get's me symptom-free and changes my life, technology is too difficult

Phone *