Sharper Mind Centers® Information Request Form
(U.S.A. only) - If your request is urgent, please call us rather than filling this out.
Welcome! and Thank you for your interest in our information.  Most of the information we sent out in the past is downloadable via this link.  However, we periodically send out updates by mail and can let you know if an office opens up in your area or include you in our e-mail newsletter.  All entries are manually scrutinized (within reason) for accuracy, completeness and to remove bogus entries.  Please use regular mixed case rather than all upper or lower case letters.  If you really serious about getting information as soon as possible, we recommend you call toll free: 1-866-435-7233 to discuss your unique situation.  Leave a message if voicemail should pick up (Call between 10:00 a.m. to 7:00 p.m. M-F Pacific Time).  You are welcome to leave a message outside of those hours. 

Field Name Colors: Red = Required; Blue = Requested; Black optional

If you wish, you may type comments regarding you and your child's situation in the box below. Make your comments all one long paragraph.  Please do NOT use the Enter or Return keys between sentences (makes the note and records difficult to import).  If you accidentally proceed to the Confirmation Form, use the back arrow in your browser window to return to the form.  You MAY use the TAB key to move between fields.

First Name(s) Last Name
Marital Status
Child First Name Child Last Name
Child Age Child Grade
Child Gender Pronoun Medication
Company or Organization
Mailing/Street Address  
  Please remember to include any apartment or suite number.
City State Zip
Closest Provider Location Country 
Phone 1    We often get mail returned as undeliverable, so please enter in case there is a mis-entry.
Phone 2   
Phone 3   
E-mail Address (enter carefully)
If you use e-mail filtering, make sure you add the www.SharperMindCenters.com domain name to your accepted list		 Add me to your E-mail list.
[Mailers are NOT done frequently.]
How did you FIRST 
hear about us?: 
Interest and Urgency: 

 
Please wait for the responder page to appear 
(time depends on the speed of your internet connection.)