Rewards for Referrals Program Form

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I am ready to earn Clinic Credits! * This field is required.List the first and last name of the person you have already recommended us to. When this person books and completes any of the following appointments with us for the first time, you will earn Clinic Credit: Free phone consult ($10), and Alpha-stim package($20), and/or a qEEG Brain Map ($40). Plus! On your very first referral, even if they never book with us, you will earn $5 of Clinic Credit just for trying this form! Clinic Credit on account is not redeemable for cash, but work just like cash in our clinic. These are immediately spendable dollars that you can choose to apply to any session, any rental, any service that we offer.
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I've been spreading the word about CBFC and my name is* This field is required.You must be an established client of Carolinas Biofeedback to participate in this rewards program.
First Name
Last Name
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Are you willing to provide a brief testimonial about your positive experience and/or great results working with Carolinas Biofeedback Clinic?This can be as short as one sentence, or can be more lengthy, and you can choose to keep it anonymous if you'd like.
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The Email Associated with my CBFC Profile is* This field is required.
example@example.com
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The Phone Number Associated with my CBFC Profile is* This field is required.
Area Code
Phone Number
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Signature* This field is required.By signing, I am attesting that I have only provided the name(s) of individual(s) I believe to be a good candidate for Neurofeedback or Biofeedback and that this person is someone that I have already personally shared with about my great experience at Carolinas Biofeedback Clinic.
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Please use this space to provide a quick testimonial that we can share on our website, our FB Page, and/or our Instagram channelPlease indicate if you would like it to be anonymous, to use first names only, or include your name. Thank you!
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