First Name *

Last Name *

Phone

Email *

Organization

City *

Which best describes you? *

State *

If you are an insurance agent, which types of insurance do you offer?

Who is your primary audience? *

Do you believe MyMindEase could help your audience? *

Approximately how many people do you reach? *

Where do you currently connect with your audience? *

Examples: Facebook, Instagram, LinkedIn, TikTok, YouTube, X, Nextdoor, WhatsApp, or other

Links or social handles

Who referred you?

Request a custom affiliate code (optional)

You will automatically receive a 7-digit affiliate code and affiliate link by email. Custom code requests are reviewed separately and do not delay your approval.

I authorize MyMindEase to register me in the Partner Program and email my affiliate code and affiliate link to the email address I provide.

I agree that MyMindEase may contact me by email about my application and partner onboarding.

Verification