Rewire and Restore
NeurOptimal® Home Rental Interest Form
Interested in a NeurOptimal® Home Rental?
Fill this out to help us understand what you’re looking for. I’ll follow up with phone call or email answering your questions.
1) Contact information
First Name
Last Name
Phone
*
Email
*
Address
Street Address
City
State
Country
Country
Postal Code
2) Rental Timing + Length
When are you hoping to start?
ASAP (within 1-2 weeks)
Within the next 30 days
In the next 1-3 months
Not sure yet / just exploring
Which rental length are you interested in?
2 weeks
1 month
3 months
Not sure — I’d like guidance
3) Who It’s For
Who is this rental for?
Just Me
Me and 1 other person
My children
Our whole household
Other
How many people live in the home?
1
2
3
4
5+
4) Goals + Hopes (your “why”)
What are you hoping neurofeedback might help with? (required — checkbox list)
Stress/Overwhelm
Anxiety/nervous system regulation
Sleep
Focus/productivity
Brain Fog
Mood/emotional resilience
Trauma/PTSD symptoms
Peak performance (sports, business, creativity)
Neurodivergence support (ADHD/autism related support)
Headaches/migraines
Other
In your own words, what would “success” look like after renting? Example: “Better sleep, less reactivity, more focus at work, calmer mornings with my kids…”
Anything else you want me to know about your situation or goals?
5) Practical Details
Do you have a quiet space to set up the system (table + chair + laptop)?
Yes
Probably/ I can make one
Not yet
Are you comfortable using a laptop and following a simple setup guide?
Yes
I think so
I would want extra support
6) Consent + Updates
Preferred way to reach you
Text
Email
Either is fine
Would you like updates about availability, openings, and rental start dates?
Yes, add me to the waitlist/updates
No, just responding to my inquiry is fine
How did you hear about Rewire and Restore?
Instagram/Facebook
Google
Referral
Returning client
Other
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