Breaking Trough the Wall of Glass

for people with Asperger's syndrome

Please tell us more about you so we can prepare for our conversation:

Your Full Name *

Your Email *

Are you requesting the call for yourself or someone else ?

I suffer from the Wall of Glass myself
I am enquiring for a loved one
I am a professional (from the medical or psychiatric fields, ...)

Have you been formally diagnosed ?

Yes, with Asperger's Syndrome / High-functionning Autism
Yes, within the Autism Spectrum Disorder
No, but there is strong suspicion I am on the spectrum

Do you suffer from or have you been diagnosed with other conditions such as PTSD, ADD or ADHD, Traumatic Brain Injury, or anything else we should know about?

What results do you want to achieve? What kind of improvement would really satisfy you?

How committed are you to putting in the necessary effort to make this transformation? Note : on average, treatment takes 6 to 10 hours.

How willing and able are you to financially invest in yourself right now?

I have the financial resources to invest in improving my quality of life right now.
I can find the financial resources to invest in improving my quality of life right now.
I don't have the financial resources to invest in myself and will have to keep things where they are.

Do you have any specific question or topic you want to adress during your call with us ?

Do you have a spouse or caretaker you need to run decisions by? (If so they should be on the call)

I realize I am booking a real time with the Peak States Clinic staff. I promise to respect their time by showing up for the time I select.

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Breaking Through the Wall of Glass

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