I want to get started at Galaxy!
Tell us a little about yourself and we will connect you with a therapist that will be able to discuss your concerns and answer any questions that you may have. This is also the starting place for all new referrals!
Home phone number:
Cell phone number:
What is your email address?
How do you prefer to be contacted?
Home phone call
Cell phone call
Have you been diagnosed with or are you experiencing any of the following? (Please check all that apply)
Traumatic Brain Injury
Concussion or Post Concussion Syndrome
Mild cognitive impairment
Progressive neurological condition
Pelvic Floor Dysfunction
At GALAXY we treat the whole person!
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This form was created inside of Galaxy Brain and Therapy Center.