REQUEST A CONSULTATION WITH THE GAME CHANGER
Complete the form below as accurately as possible. Please allow 24 hours for response.
If your matter is urgent, please call 647-688-2216. If you're in an emergency situation please call 911.
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Name:
Email:
Comment:
First Name
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Last Name
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Phone Number
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Country
Email Address
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Website
Company
Who is this Session for?
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The 3 major problems with your Brain and/or Health
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The 3 major problems in your Career and Life
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What are the Outcomes that you are seeking?
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Existing Medical Conditions:
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Existing Medications:
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Most prominent problems (please rate from 0 to 10)
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List childhood injuries, falls, concussions (MTBI)
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List any medications taken in the past (age?)
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List Therapies and Treatments you’ve tried:
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On a scale of 1 to 10 rate how successful these treatments have been. 1 - no difference. 10 - very successful.
Anything else you would like us to know?
What are you Seeking?
1-on-1 Online Brain & Body Mastery Session with The Game Changer
Book a QEEG Brain Mapping & Neuro-Assessment
Book a Session at The Game Changer Practice
Please Check all that apply
Headaches
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Drink Alcohol
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Vision problems
Attention Issues
Memory Issues
Anxiety
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Smoke
Stressful Events
Weight Issues
Physical Health Issues