NFI Client Intake Form Name First Last Email Date Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneHow did you find out about us?*ReferralMedia storyWeb searchEventOtherFor whom are you making this inquiry?*MeSomeone elseAre you interested in planning an EVENT?*Health and WellnessClinical RehabilitationAthletic PerformanceMasters of Mobility/Active AgingBusiness BuildersHealth and WellnessBrain and Body ConditioningNeuroplastic Functional Training for personal advancementNeuroplastic Functional Training for use in a health care practiceNeuroplastic Functional Training to become a health and wellness Neuroplastic Functional TrainerOtherClinical RehabilitationInjuries and Disease Processes such as Parkinson's Disease, Traumatic Brain Injury, and StrokeNeuroplastic Functional Training for personal advancementNeuroplastic Functional Training for use in a health care practiceNeuroplastic Functional Training to become a health and wellness Neuroplastic Functional TrainerOtherMasters of Mobility/Active AgingMovement Education and Cognitive HealthNeuroplastic Functional Training for personal advancementNeuroplastic Functional Training for use in a health care practiceNeuroplastic Functional Training to become a health and wellness Neuroplastic Functional TrainerOtherAthletic PerformancePerformance, Injury, Prevention, and injury ManagementNeuroplastic Functional Training for personal advancementNeuroplastic Functional Training for use in a health care practiceNeuroplastic Functional Training to become a health and wellness Neuroplastic Functional TrainerOtherBusiness BuildingNeuroplastic Functional Training for personal advancementNeuroplastic Functional Training for use in businessNeuroplastic Functional Training to become a corporate Neuroplastic Functional TrainerOtherSpinal Code Injury ProgramAquatic Immersion ProgramNeuroplastic Functional Training for personal advancementNeuroplastic Functional Training for use in a health care practiceNeuroplastic Functional Training to become a clinical Neuroplastic Functional TrainerOtherOnline Subscription-Based ProgramsNeuroplastic Functional Training (NFT) Movement Education Classesimovethematrix - Global brain and body conditioningBrains Bones Balance - OsteopororosisAthletic CoreYogaMeditationBack ClassJoint ReplacementRange of MotionLife EducationAddictionLearning DifferencesFear and Stress ManagementSelf RegulationAcquisition of GoalsWeight LossMeditationMore Information about how we can help...Please give more information as to how we can specifically help you in the areas that you checked above.