Brain Health Reboot Intake Form
Help us personalize your 8-week Brain Health Reboot experience. Share your motivations, challenges, and goals so we can best support your journey.
Welcome to the Brain Health Reboot Intake Form!
This 8-week program is designed to help you uncover what hijacks your focus and energy, create a nutrition plan for optimal brain performance and emotional steadiness, add realistic movement, address lifestyle habits that impact brain-body communication, support your midlife transitions, and explore how creativity can benefit your health. Your responses will help us tailor the program to your unique needs.
Your Name
*
First Name
Last Name
Email
example@example.com
What motivated you to join the Brain Health Reboot program?
*
Are you aware that during this program I am your accountability partner and You can reach me by text at anytime to answer simple questions? Will an accountability partner make your journey easier?
Yes absolutely
No I can be self motivated once I know what to do
I would love to ask questions when they come to me, brain fog is real!
I am afraid to ask stupid questions
What are your biggest daily challenges related to focus, energy, or emotional steadiness? Please feel free to list any physical or brain health issues you would love to see resolved.
*
Which of the following best describe your current eating habits? (Select all that apply)
Regular meals/ 3 day plus a snack
Frequent snacking
Mostly home-cooked food
Mostly takeout or restaurant food
Vegetarian or plant-based
High-sugar foods/ I crave them especially mid day
Irregular eating schedule/shift work
Other
How do you currently move your body? (Select all that apply)
Walking/running 3x a week
Yoga or stretching 2x a week or more
Strength training
Group classes
Little to no movement, I am too busy
Other
How often do you engage in creative activities (art, music, writing, etc.)?
Daily, I love to create
A few times a week, just for fun
Occasionally, If I am invited to
Rarely, I don't feel very creative/ I don't have time
Never
What shifts are you hoping to experience in your brain or body during this program?
*
Is there anything else you’d like us to know to best support you during this program?
Register
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