| |
Dr. Mr. Ms. |
| * First Name: |
|
| * Family (Last) Name: |
|
| Middle Name: |
|
| * Street Address: |
|
| * City: |
|
| * State/Province: |
|
| * Country: |
|
| * Postal Code: |
|
* Telephone:
|
|
| Fax: |
|
| * E-mail Address: |
|
May we have your permission to put you on our opt-in mailing list?:
(Your privacy is respected. Contact and other personal information are never shared with third parties of any kind.) |
|
| Your Age: |
|
|
* How did you discover this site? By way of an Internet search engine or directory? If so, which one?
|
|
| * Our offices are located in the Los Angeles, CA area. If you live outside the area, would a trip to Los Angeles for a week or so be possible if you were reasonably sure the result would be permanent eradication of your fear/phobia/panic/anxiety? |
|
| * The required investment for participation in our revolutionary Accelerated Personal Breakthrough Coaching™ program generally runs between $125 and $6500, depending on the nature and severity of your anxiety problem. If you were reasonably certain participation in our program would result in permanent alleviation of your fear/phobia/panic/anxiety, would such an investment be possible for you at this time? |
|
|
Considering all of the above, do you have any questions or comments? Please tell us here:
|
|
* May we contact you by telephone to discuss this?
If so, please be sure to note a telephone number (above) that does not use Caller ID Block, a Privacy Manager system, or other such screening mechanism. If you do, we may not be able to contact you as per your wishes. |
|
| If so, what is the best time to reach you? |
|
|
Thank you for contacting us!
|
|
| Privacy Policy: We appreciate your choice to contact us in confidence and with the expectation that your privacy will be respected at all times. At no time does BrightLife ever share, sell or otherwise distribute personal or contact information with third parties of any kind. If you have any questions about our Privacy Policy, please contact us by email at privacypolicy@fearintopower.com. |