FIRST NAME *

LAST NAME *

EMAIL ADDRESS *

WHERE ARE YOU BASED? *

Enter your country

Dr Gladys works with clients internationally

WHICH MEDICAL CONDITIONS? *

Tinnitus

Hyperacusis

Hearing loss

WHICH SOLUTIONS YOU TRIED ALREADY? *

Tinnitus counselling

Mindfulness or meditation

Sound therapy or masking

Hearing aids

Medication or supplements

Nothing yet

Other

WHAT WOULD YOU LIKE TO ACHIEVE WITH COACHING?

DO YOU HAVE ANY OTHER MEDICAL CONDITIONS YOU NEED ME TO KNOW ABOUT? *

Yes

IF YES, PLEASE SPECIFY BELOW

ARE YOU IN A POSITION TO INVEST £500 TO £3000 GBP IN COACHING FOR TINNITUS RELIEF? *

Yes

Please note: Currently, pre-assessment calls are currently limited to applicants who are able to invest in the programme. If cost is the only concern, payment plans are available. Tell us on this form and we can look at what works for you.

ARE YOU IN A POSITION TO INVEST $650 TO $4000 USD IN COACHING FOR TINNITUS RELIEF?

Yes

DO YOU HAVE ANY COMMENTS OR QUESTIONS?

By checking this box, I consent to Dr Gladys Sanda storing and processing the information that I have shared for the purpose of reviewing my suitability and contacting me about next steps. I also agree to receive occasional emails relevant to tinnitus support and know that I can unsubscribe at any time. My details will never be shared with anyone else.