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Donation Request Form

Thank you for applying to receive assistance towards participating in our highly successful DNRS home study program! Our ability to provide our clientele with copies of the program depends on the generosity of past DNRS participants and other charitable donors whom are willing to provide financial assistance to those in need.

This form is used by our management staff to determine your eligibility when a donation becomes available.  Please take the time to answer all of our questions by filling out our donation request form below. You will receive confirmation that your application has been received. Please note that the DNRS home study program is for individual personal use only and includes one free membership to the DNRS Community Forum. We ask that you do not share the program or your forum membership with others.

Due to the large number of inquiries that our that we receive on a daily basis, only those who are selected to participate in the program will be notified.

Thank you for reaching out to the Dynamic Neural Retraining System.

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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