I am interested in...
I prefer to work with....
A male practitioner
A female practitioner
I don't have a preference
I identify as...
Prefer not to say
Physical health conditions
IBS/abdominal pain/frequent GI symptoms
Fibromyalgia/widespread pain/chronic fatigue syndrome
Autoimmune conditions/chronic infections
Are there certain modalities you would like to be utilized in session?
Nervous system regulation/polyvagal
I would like to receive future communications
I agree to the GDPR & CCPA Terms & Conditions
I confirm that I am at least 16 years of age or older
I have read and accept any EULA, Terms and Conditions, Acceptable Use Policy, and/or Data Processing Addendum which has been provided to me in connection with the software, products and/or services.
I have been fully informed and consent to the collection and use of my personal data for any purpose in connection with the software, products and/or services.
I understand that I have the right to request access annually to any personal data you have obtained or collected regarding me. You have agreed to provide me with a record of my personal data in a readable format.
I also understand that I can revoke my consent and that I have the right to be forgotten. If I revoke my consent you will stop collecting or processing my personal data. I understand that if I revoke my consent, you may be unable to provide contracted products or services to me, and I can not hold you responsible for that.
Likewise, if I properly request to be forgotten, you will delete the data you have for me, or make it inaccessible. I also understand that if there is a dispute regarding my personal data, I can contact someone who is responsible for handling data-related concerns. If we are unable to resolve any issue, you will provide an independent service to arbitrate a resolution. If I have any questions regarding my rights or privacy, I can contact the email address provided.
Thank you for filling out this form, we will contact you to set up a discovery call.