Free Mold Consultation

Request Form

Please fill out this form and a specialist will get in contact with you to schedule your free mold consultation.

Personal Information

First Name *

Last Name *

Date of Birth *

Gender *

Male

Female

Phone *

Email *

Preferred method of contact? *

Phone

Email

Text

Where did you hear about this? *

Mold Exposure History

Do you know or suspect mold in your (home, work, school)? *

Are you currently living in a moldy environment? *

Yes

No

Unsure

Please describe your symptoms: *

TESTING:

Have you done any mold testing for your home? *

Have you done any mycotoxin testing for your body? *

Any other testing or labs you'd like to tell us about?

TREATMENT:

Are you currently doing any treatment or detox methods? *

Yes

No

Kind of

Treatments

What stage of treatment would you say you’re in right now? *

Stage 1. I haven’t done anything yet - This is my first time seeking help

Stage 2. I’m just getting started - I’ve done some treatment methods or tried some supplements

Stage 3. I’m in the middle of treatment right now - but I’m looking for additional support

Stage 4. I’ve done a complete mold protocol - but I still have issues

Stage 5. Other (explain below)

Other

Goals and Challenges

What's been your biggest challenge when dealing with mold? *

What do you hope to learn and gain from this free mold consultation? *

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Full Name *

Date *

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