Donation Request Form

* First Name:

* Last Name:

* Email:

* Phone number including area code:

* Age:

* Address:

* City:

* Province/State:

* Country:

* Postal/Zip Code:

* How did you hear about Dynamic Neural Retraining System?

* Are you currently working?
YesNo

* Are you currently receiving financial assistance?
YesNo

Do you identify as part of the BIPOC (Black, Indigenous, People of Color) Community?
YesNo

* What challenges or condition(s) brings you to this program?

* How has this issue affected your quality of life?

Any other information you wish to add?

* Are you willing to give a written or filmed testimonial of your recovery using your first name only?
YesNo

* I acknowledge that the Dynamic Neural Retraining System is not a medical treatment, nor is it intended to replace the services of a physician.
YesNo

* I understand that on-going daily commitment and practice is vital in order to strengthen and reinforce the new brain pathways that are being formed.
YesNo

* I have completed the Self-Assesment Survey and answered ‘yes’ to more than 5 of these questions?
YesNo

* I have a tremendous desire to move forward in my life.
YesNo

* I agree to implement the Dynamic Neural Retraining System training daily for a minimum of 6 months.
YesNo

Were you referred by a Doctor? If so please fill out the following:
Doctor’s Name

Doctor’s City

Doctor’s Province/State

Doctor’s Phone Number (optional)

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