Making Peace with Pain
Home
Apply to be a Beta Tester Today
Beta Test Application Form
To apply to be a beta tester, please fill out this form.
Take your time and answer honestly.
If the program is not a good fit for you then your being part of the beta wont work for you or me.
*
Indicates required field
Please tell me what condition/s you have.
*
Fibromyalgia
Arthritis
Migraines
Irritable bowel syndrome or other indeterminate digestive issues
Joint, muscle or bone aches and stiffness
Frozen shoulder, repetitive strain or poor usage issues
Feet or knees that just hurt or have stiffened and restricted motion
Autoimmune conditions - thyroid/Hashimoto's etc
Other
If Other please specify:
*
What is your age? (I am not looking for a particular age, but I would like a variety of ages in the beta cohort)
*
Less than 13
18-25 (sorry, no under 18's this time round)
25-35
35-50
50-65
Over 65
Where are you located? (I'm hoping for participants from a range of locations is always good!)
*
Australia - east coast or central
Australia - west coast
Pacific Island, incl New Zealand & Hawaii
East Asia
West Asia (ie India, Bangladesh)
Middle East
North Africa
Southern Africa
Eastern Europe
Western Europe
USA/Canada - East Coast
USA/Canada - Central
USA/Canada - West Coast
Central America
South America
Other
If Other, please specify:
*
Tell me a little about your pain journey: when did each condition start, how has it progressed, what you've tried as treatment and what has been the result.
*
Have you ever tried any alternative therapies for your pain condition? If so, what did you try and how did you find it?
*
What's are the biggest problems your pain condition has caused you? (this could be a physical thing, or an emotional thing, or some part of life you can't engage in the way you'd like).
*
Terms and Conditions of Beta Test Application Process
Your privacy is extremely important to me. I understand that the information you've shared here may be very personal to you and I want to assure you that it will be held only as long as required, and then destroyed/deleted and removed from any archives or storage. If you're accepted into the beta program, your information will be retained in secure electronic storage until the end of the program and the final feedback from you is received.
Some answers may be retained in de-identified form for use in marketing materials. No answer that could identify you will be used in this manner. These will not be treated as "quotes" or "testimonials", but simply inform the language of marketing materials. If quotes or testimonials would be useful, you will be asked specifically for them.
This information will be viewed only by Naomi Crain, and any other staff or volunteers who require access to complete the tasks assigned them. All such staff or volunteers will sign a privacy agreement with a non-disclosure statement. It is not expected that anyone other than Naomi will view your application.
By giving your name, email and clicking submit application, you agree to these terms and conditions.
Name
*
First
Last
Email
*
Submit application
Home
Apply to be a Beta Tester Today
Beta Test Application Form