The NeuroDesign Method™ Application Form

Your nervous system already knows if this is your next step.

Let’s see if this is the right fit for you.

First Name *

Last Name *

Phone *

Email *

City, State, Country *

What are the PRIMARY symptoms or patterns you’re seeking support with? (Multi-select) *

Other:

On a scale of 1–10, how much is this affecting your day-to-day life? (1 = mild, 10 = deeply affecting my function) *

Have you tried anything before to regulate your nervous system? What helped, and what didn’t? *

What draws you specifically to The NeuroDesign Method™? *

What would your life look or feel like if you were fully regulated, grounded, and clear? *

Are you ready to commit to Season 1: a 3-month nervous system restoration journey? *

Yes — I’m ready for long-term transformation

Yes, but I have questions

No

Are you open to integrating body-first tools like breathwork, positioning, fascia drills, and emotional unwinding? *

Yes

I think so, but I’ve never done them

No

Have you ever worked with me or attended any NDM trainings before? *

Yes

No

Do you identify as any of the following? *

Over-thinking high performer

Emotional empath

Parent with sensory overload

Spiritually-aware but dysregulated

Practitioner/leader who “knows a lot but can’t integrate it”

Other (optional)

If accepted, how do you plan to fund the program? *

Pay in full

Weekly payments

I'm not sure yet

I would like to apply for a financial grant

If you selected financial grant, please briefly share your current financial situation so we can consider you for grant support.

Why NOW? Why is this the right moment for you to do this work? *

Is there anything else you want Jillian to know before your call? *

Step Into Your Next Chapter

After you submit your application:
- You’ll be taken to the page to book your call with Jillian.
- On the call, we’ll explore your patterns, goals, and whether this method aligns with what your nervous system needs.