First Name *

Last Name *

Email *

Phone *

How Did You Hear About Us?

Preferred Method Of Contact *

Phone

Text

How Can We Support You? *

Stress, Anxiety & Emotional Well-being

Sleep Issues & Fatigue

Focus, Attention & Productivity

Memory & Cognitive Performance

Brain Fog & Mental Clarity

Chronic Pain & Physical Recovery

PTSD & Trauma Recovery

Headaches & Migraines

Mood Regulation & Emotional Resilience

ADHD, Learning & Developmental Support

Peak Performance for Sports, Business, or Creativity

Brain Health & Aging (Alzheimer’s/Dementia Prevention)

Nervous System Regulation & Sensory Overload

Concussion & Traumatic Brain Injury (TBI) Recovery

Is Insurance Coverage an Important Factor for You? *

Yes, I would like to explore insurance coverage options.

No, I will be paying out of pocket.

I’m unsure—please provide guidance.

I Am Interested In: *

In-Center Neurofeedback (Sessions at our Colorado Springs location)

At-Home/Remote Neurofeedback Rental (Short or long-term rental for personal or business use)

Purchase a NeurOptimal® System (For personal or professional integration)

QEEG brain mapping

Coaching (High-performance, mindset, or life coaching)

Counseling (Mental health support with a licensed therapist)

LifeWave Phototherapy (Wellness patches for energy, recovery, and sleep)

BioMat Session or Purchase

Anything else you’d like to share?

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