General Information Request / Contact | Brain Integration Therapy and Consulting

General Information Request

Full Name *

Email address *

Phone: *

Message *

Location: *

Client's Full Name: *

Why are you seeking our services: *

Has your child received a diagnosis? If, yes, please share it. *

Have you received a diagnosis? If, yes, please share it. *

What therapies or interventions have you tried? *

What are you hoping to improve or see change in your child or yourself, if you are seeking services for an adult? *

Which program are you interested in joining? *

In-Person in Dublin Ireland
Virtual

Are you interested in an intensive therapy program (1-4 weeks, 2-4 hours per day) *

Yes
No
Not sure yet, I'd like more information

I Consent to Receive SMS Notifications, Alerts & Occasional Educational Communication from Brain Integration Therapy & Consulting *

Yes