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T. K. Wolf Services Cranial Electrical Stimulation (CES) Successful & Cost Effective Solutions Benefits of CES Get More Information References Stressed?  Anxious?  Depressed?  Can't sleep?  Addicted? Don't want prescription drugs?  Tried everything? Try Cranial Electrical Stimulation (CES)! CES has been researched for decades, and is cleared for use by the FDA! To see if CES is right for you, fill out the following form and we will contact you. Please fill out all information.  This information will be held confidential and an individual code number will be assigned. First & Last Name:   Birthdate:   Address Line 1:  Address Line 2:  City, State, Zip:   ,   Phone Number       (with area code):   () Email Address:   To help us insure your confidentiality we ask that you provide us with your mother's maiden name.  This will allow us to confirm that we are speaking with you when we call. Mother's Maiden   Name:     1.  I suffer from (please check all problems that apply to you):     Stress Anxiety Depression Insomnia   2.  I suffer from addiction (check all that apply):     Alcohol Nicotine Prescription Drugs Street Drugs     Food Work Relationships Gambling     Computers Religion Other (please specify)   3.  I have had this problem for Weeks Months Years 4.  I have attempted to address my problem(s) in the following ways:  (Please describe.  E.g. prescription drugs (list drugs, e.g. Prozac, Zoloft, Xanax, etc.), counseling, AA/Alanon, support groups, prayer/religion, etc.)   5.  I think the cause of my problem is:  (Please describe.  E.g. physical, emotional, trauma, abuse, etc.) 6.  This problem affects my (check all that apply):     Family Relationships Health Job   7.  This problem costs me approximately $ per Week Month Year     (Include cost of all drugs, alcohol, cigarettes, counseling, health care, etc.) 8.  I want help with this problem because:     Thank you to Active iNet Services for hosting this website.    visitors since March 9, 2006