Initial Questionnaire – HOW Foundation of South Florida

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Initial Questionnaire

Fill out our short questionnaire below and a member of our team will get in touch with you to discuss ways we may be able to work together.

Name *

Email Address *This will only be used to communicate and share resources with you.

Phone *

For which program are you seeking HBOT treatment? *

For which condition(s) are you seeking HBOT treatment? *

Brain injury (including concussion)Post-traumatic stressOther

Do you struggle with any of these ailments?

Cognitive issuesLung issuesEar issuesHeadachesSeizuresOther (please describe below)Select any that apply.

Please provide any helpful details.

Are you or have you been a member of the US military? *

Are you currently employed? *

Will you need financial assistance to participate in HBOT? *

Consent *

Yes, I agree that HOW Foundation may use the information I have provided to assess my situation and to contact me for follow-up.

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Please do not fill in this field.

HOW Foundation of South Florida
EIN 46-3568088
1030 Wallace Drive, Suite C
Delray Beach, FL 33444

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