Application Form

New Client Intake

  • Date Format: MM slash DD slash YYYY
  • Client Information

  • Health Information

  • Drop files here or
    Upload any relevant files
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    Please let us know what was the source that refereed you to us
  • Privacy Agreement

    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.