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529 Houston St Coppell, TX 75019
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(469) 830-2090
Home
About Us
Blog
Programs
Services
New Patients
Visitors from Out of State
Provider Referral Form
Partners
Partnerships
Affiliates
Contact Us
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(469) 830-2090
Contact Us
Fill out the contact form below to get started. We look forward to helping you achieve your health goals and live your best life.
Contact Us
We look forward to helping you achieve your health goals and live your best life.
Fill out this contact form to get started.
Someone from our team will reach out to you to continue the conversation about how we can best support you in your recovery and wellness journey.
Send Us a Message
Contact Form
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First Name
Last Name
Email
Phone
What is your age?
Where are you located? (City/State or Zip Code)
What brings you here today? (Select all that apply)
Concussion / Head Injury
POTS / Dysautonomia
Dizziness / Balance Problems / Vertigo
Stroke Recovery
Neuropathy
General Health Screening
Brain Health Lifestyle Coaching
Other (type in below)
What brings you here today? (not listed above)
Have you ever been diagnosed with a Concussion, TBI, or Stroke?
Yes
No
If yes, when did it occur? (Date/Approximate)
Have you noticed ongoing symptoms since then?
Yes
No
How much do your symptoms interfere with daily life?
Mild (noticeable but manageable)
Moderate (affects work/school/social life)
Severe (limits daily activities and quality of life)
Which symptoms are most disruptive for you right now? (Select all that apply)
Headaches
Dizziness/Vertigo
Memory Loss / Cognitive Deficits
Mood Changes
Sleep Issues
Loss of Movement / Motor Function
Speech Deficits
Other
If Other, please list most disruptive symptoms.
Are you currently seeing another medical provider for these concerns?
Yes
No
Have you tried any of the following? (Select all that apply)
Neurology
Physical Therapy
Chiropractic Care
Functional Medicine
Medications
None of the above
On a scale of 1-10, how ready are you to actively work on your recovery? (10 is most ready, 1 is least ready)
Are you looking for:
In-person care
Online coaching/programs
Not sure
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