First Name *

Last Name *

Email *

Phone *

Please list the symptoms you are seeking help for: (please keep your answers to simple list of symptoms/diagnosis) *

Are you currently taking any medications for anxiety, sleep, or depression? *

Why is it important for you to work on this now? (select all that apply) *

I’m tired of my symptoms controlling my life

I’ve tried other approaches and nothing has worked

I’m ready to actively do the work required to create change

This program requires daily action (approximately 30–45 minutes) How ready are you to commit? *

What is the main outcome you want to experience by the end of MBR? *

When would you ideally want to begin the program? *

Immediately

Within the next month

In 1-3 months

Once you click the "Submit Application" button below, you will be redirected to a confirmation page. We will review your application and get back to you within 24-48 hours.