Who is this application for? *

Myself

My child or a young person in my care

Another adult whom I am assisting

Patient's Full Name *

Patient's Date of Birth *

Primary Email Address *

Primary Phone Number *

Street Address

City

State

Country

Postal Code

Which area feels closest to what you are seeking help with? *

Please tell us briefly what has been happening. *

Please include when the problem began, the main symptoms or difficulties you are experiencing, and how they are affecting your life.

What would you most like to be different? *

For example, being able to think more clearly, return to work, sleep better, recover from a concussion, feel less overwhelmed, or better understand what may be contributing to your symptoms.

Which statement best describes where you are at right now? *

I am mainly gathering information

I am interested, but I am not yet sure what I could manage

I am ready to begin if NeuroBalance appears to be a good fit

I am ready to make this a priority

Could you attend the Dunedin clinic if an in-person assessment or programme were recommended? *

Yes

Possibly

No — I would need remote options

I am based outside New Zealand

Anything else you would like us to know? *

I understand that submitting this form is an application and does not create a confirmed appointment or establish an ongoing clinical relationship. I give NeuroBalance permission to review the information provided and contact me about possible next steps.

I agree to the collection and use of my information as described below.

Why we collect this: NeuroBalance collects your information to evaluate whether our services are right for you and to contact you about next steps.
Who sees it: Your details are accessed only by authorised NeuroBalance team members and held securely by us and our approved service providers.
Your choices & rights: Providing this information is voluntary, though we may not be able to process your application without mandatory details. You can request access to or correction of your information anytime by emailing [email protected]. For full details, please review our Privacy Policy. Collected in accordance with Rule 3 of the New Zealand Health Information Privacy Code 2020.