Biofeedback Interest Form

Please complete the form below, and we will be in touch with you shortly.

Name *

First

Last

Email *

Phone *

Select which kinds of issues you are seeking Biofeedback Services for: *

• Headaches
• Insomnia
• Chronic Pain
• Fibromyalgia
• Hypertension/Cardiac conditions
• Diabetes management
• Addictive behaviors
• Gastro-intestinal problems
• Anxiety/Depression/ADD
• Panic/PTSD
• Arthritis/Rheumatological problems

Tell us a little more about your interest in Biofeedback. Where did you hear about it? Are you being referred by a medical doctor? *

Are you currently a patient at IPG? *Please selectYesNo

What's your therapist's name?

Submit