605 Cherry St. Suite 320, Belton, MO 64012
(816) 226-4678

Do you have a sleep problem?

    My work or other activities prevent me from getting at least 7 hours of sleep:

    My bedtime or waketime varies by more than 3 hours:

    It takes me 30 minutes or more to fall asleep:

    I am awake for 30 minutes or more during the night:

    I wake up 30 or more minutes before I have to and can’t fall back asleep:

    I am tired, fatigued, or sleepy during the day:

    Do you want to be able to fall asleep, stay asleep during the night, and sleep until your alarm sounds without having to rely on alcohol, sleep medicines, or other interventions?

    How long have you had this struggle with sleep?

    In what ways is sleep a problem for you? Please describe.

    Your Name (required):

    Your Email (required):

    Your Phone Number:

    How do you prefer to be contacted?

    Your Zip Code* (required):

    * Must live in Kansas or Missouri