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I want to get started at Galaxy!
Tell us a little about yourself and we will connect you with a therapist that will be able to discuss your concerns and answer any questions that you may have. This is also the starting place for all new referrals!
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* Indicates required question
First name:
*
Your answer
Last name:
*
Your answer
Home phone number:
Your answer
Cell phone number:
Your answer
What is your email address?
Your answer
How do you prefer to be contacted?
*
Home phone call
Cell phone call
Text Message
Email
Other:
Have you been diagnosed with or are you experiencing any of the following? (Please check all that apply)
*
Traumatic Brain Injury
Concussion or Post Concussion Syndrome
Parkinson's
Stroke
Mild cognitive impairment
Brain Tumor
Progressive neurological condition
Vertigo
Pelvic Floor Dysfunction
Other:
Required
At GALAXY we treat the whole person!
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