Application Form

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Client Information
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Health Information
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Have you ever experienced any of the following?*
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- Phobias
- Panic attacks
- Anxiety
- Sleep disturbances
- Hallucinations
- Alcohol/substance abuse
- Eating disorder
- Body image problems
- Repetitive thoughts (e.g. obsessions)
- Repetitive behaviors (e.g. frequent checking, hand washing)
- Homicidal thoughts
- Suicidal attempts
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Our privacy policy is our professional and legal statement that we manages client's data strictly and Privately . We fulfill a legal requirement to protect client's privacy with our Non-Disclosure Agreement. However, The Pierce Institute, may use your email and phone to contact you on upcoming events.
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