Your Name:

Date of Birth:

Email:

Contact Phone:

Qualifying Condition: The patient has been diagnosed with the following debilitating medical condition by a qualified, licensed health care provider or mental health professional. This diagnosis is stated in the official clinical documentation that will be submitted to Wholistic ReLeaf.
PLEASE SELECT A MEDICAL CONDITION FROM THIS LISTAcquired immune deficiency syndrome (AIDS)Aggressive Behavior/Conduct DisorderAlopecia areataAmyotrophic lateral sclerosis (ALS)Anorexia/Loss of AppetiteAnxiety (Chronic)Aphonia/Inability to SpeakApraxia/Inability to SpeakArthritis (Chronic Joint Inflammation)Arthritis (Osteoarthritis)Arthritis (Rheumatoid)Attention and concentration deficitAttention deficit disorderAttention Deficit Hyperactivity DisorderAutismAutoimmune encephalopathyAutoimmune hemolytic anemiaBipolar disorderCancerCeliac diseaseCerebral folate receptor autoimmunity/deficiencyChronic Abdominal PainChronic fatigue syndromeChronic pancreatitisCrohn's diseaseDepression/DysthymiaDifficulty Swallowing/DysphagiaDiverticulitisDyskinesiaDystoniaEpilepsyFibromyalgia/myopathic encephalopathyGlaucomaGrave's diseaseGuillain-Barré syndromeHashimoto's thyroiditisHeadaches (Chronic)Human immunodeficiency virus (HIV)Huntington's diseaseIdiopathic thrombocytopenic purpura (ITP)InsomniaIrritability and AngerIrritable bowel syndrome (IBS)Juvenile ideopathic (rheumatoid) arthritisMajor DepressionMigrainesMultiple sclerosisMuscle Pain/MyalgiaMuscle SpasmMyasthenia gravisNausea (Chronic)Neuropathic Pain/NeuralgiaObsessive Compulsive Disorder (OCD)Obsessive/Compulsive Thoughts and ActsPanic AttacksParkinson's diseasePediatric Acute-onset Neuropsychiatric Syndrome (PANS)/ Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS)Pelvic PainPolyarteritis nodosaPost-Traumatic Stress Disorder (PTSD)PsoriasisRestless leg syndromeRheumatoid arthritisScleroderma/systemic sclerosisSeizure disorderSjögren’s syndromeSLE/lupusSocial Phobia/AnxietyStress ReactionTerminal medical condition, as stated by the physician specialist treating for that conditionTic DisorderTourette'sTremorsType I diabetesUlcerative colitisUnspecified speech disturbancesViolent BehaviorsVitiligoVomiting (Chronic)Other Condition (describe below)

Other Condition (if not listed above):

Zip Code:

How You Heard About Us:
PLEASE SELECT ONE OF THE FOLLOWINGSearch engineSocial Networking SiteNewspaperTVRadioFriend/FamilyReferred by a physicianOther Source (describe below)

Other Source (if not listed above):