MemGram® Funding -

Submit this form to apply for MemGram® Processing funding.

Your Name:*
First Last
Email:*
Phone:*
Orientation Session Date:*
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DD
YYYY
# Traumas: Remaining To Be Processed*
Your Main Physical or Emotional Concern:*
What is there about your situation that requires funding to receive MemGram® Processing?*
How much funding do you need per session? Choose one.*
- $0.50 Per Minute Discount From $2.95
- $1.00 Per Minute Discount From $2.95
- $1.50 Per Minute Discount From $2.95
- I Need to Pay Maximum $50 Per Session
- I Need to Pay Maximum $30 Per Session
- I Am Destitute.
Dr. Martin's rate is $2.95. Other CMP rates range from $1.95 to a fixed $75. If you completed your Orientation with Dr. Martin and you request Funding you will be assigned to another CMP of our choice unless you prefer a specific CMP.
Preferred Certified MemGram® Processor:
For what MemGram® Level are you applying for funding?*
If this request is not for Level-1, please describe what the previous MemGram® Level did for your life:*