Financial Aid Application

Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Date of MS Diagnosis

MM

DD

YYYY

Submitting Doctor's Note? *

please email to info@ms-impossible.org.

Yes

No

Type of Healthcare Service *

Dietician

Fitness Coaching

Holistic Wellness

Massage Therapy

Physical Therapy

Resiliency / Life Coaching

Other

Are you interested in working with a practitioner in our Practitioner Network? *

Yes

No

If yes, please indicate which practitioner you would like to work with:

Ahna Kennedy, Nutrition & Holistic Wellness

Brent George, Physical Therapy

Daniel Jahn, Fitness Coaching

Laura Tobin, Massage Therapy

Maureen Manley, Resiliency Coaching

Raanah Amjadi, Holistic Wellness