Multiple Chemical Sensitivities Treatment and Recovery from Environmental Illness , Chronic Fatigue Syndrome, and Fibromyalgia

Registration for In-Person Program

Thank you for your interest in the Dynamic Neural Retraining System™. To express interest in registering for an upcoming program, please fill out the form below.

Note that your interest does not guarantee you a spot in the program and all applicants are interviewed to determine candidacy for this program. Please note that we take applications on a first come, first serve basis therefore in order to proceed with the registration process we require you to complete the following questions and return a.s.a.p.

Thank you.

Location and date of workshop you are applying for: *

Name *

Gender *

Male
Female

Address *

City / Town *

Province or State *

Country *

Postal Code / Zip *

Telephone (area) + phone number *

Age: *

How did you hear about the program? *

What challenge or condition brings you to this training? *

When did your issues begin? *

Do you know what triggered this issue? *

How has this issue affected your life? *

I want you to envision yourself completely recovered from this issue. What is available to you then? *

How will this affect your daily living? *

How will it make your life more enriching? *

How will all this affect your friends and family? *

Any other information you wish to add?

E-mail Address: *

* Required

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