Please fill out the form below to register, once we verify your information we will inform your practitioner, if you don’t have a practitioner, we will help you find one. Client Disclaimer Client Name* First Last Email* Phone*Do You Already Have a Practitioner?*If You Don't Have a Practitioner...Don't worry, we'll match your symptoms with the right ACT Practitioner Yes No Please list your symptoms and how long you've had them?*Practitioner Name*Enter your Practitioner info here, if you don't have one, we can help you find a Practitioner. Practitioner Phone Number* Practitioner Email* They will be notified by email that you signed the disclaimer. Disclaimer*Check the I AGREE box below, to agree to the terms on the DISCLAIMER PAGE - CLICK HERE TO VIEW. Disclaimer I AGREE Would you like a practitioner to call you?* Yes, Have Someone Call me No, I'm Not Interested