Find out how Dr. Titus Chiu's innovative approach to brain health can help you get your brain AND your life back by completing our New Patient Application.
Spots are limited so apply today!
Just a few basic questions so we can get to know a bit about you
Question 2 of 30
Patient's First Name
Question 3 of 30
Patient's Last Name
Question 4 of 30
Contact Person's Name - Relationship to PatientPut NA if this doesn't apply to you.
Question 5 of 30
Phone Number (555-123-4567)
Question 6 of 30
Best timeframe to reach you (Pacific Standard Time)
Morning (8am - 12pm)
Afternoon (12pm - 4 pm)
Evening (4pm - 7pm)
Question 7 of 30
Confirm Your Email Address
Question 8 of 30
Location (City, State, Country)
Question 9 of 30
Date of Birth (DD/MM/YYYY)
Thanks for completing the first part of your application. Just two more sections to go!
Question 11 of 30
Why are you interested in working with Dr. Titus Chiu and the BrainSAVE! approach to brain health? What makes you think this is the right program for you?
Question 12 of 30
Briefly, what is your health goal?
Question 13 of 30
What is your biggest frustration in reaching your health goal?
Question 14 of 30
If you had a magic wand and could erase three problems, what would they be?
Question 15 of 30
What have you tried so far that HAS worked for you?
Question 16 of 30
What have you tried so far that HASN'T worked for you?
Question 17 of 30
How much time would you be willing to invest to overcome your health challenge once and for all?
Question 18 of 30
If you could have one question answered about your health challenge, what would it be?
Question 19 of 30
How did you hear about us?
Last section– you got this!
Question 21 of 30
How ready/willing are you to significantly modify your diet (1 = Not Willing and 5= Totally Willing)
Question 22 of 30
How ready/willing are you to take nutritional supplements every day (1 = Not Willing and 5= Totally Willing)
Question 23 of 30
How ready/willing are you to modify your lifestyle (i.e. work demands, stress management? (1 = Not Willing and 5= Totally Willing)
Question 24 of 30
How ready/willing are you to practice relaxation techniques (1 = Not Willing and 5= Totally Willing)
Question 25 of 30
How ready/willing are you to engage in regular exercise (1 = Not Willing and 5= Totally Willing)
Question 26 of 30
How ready/willing are you to have periodic lab testing to assess your progress (1 = Not Willing and 5= Totally Willing)
Question 27 of 30
Are you willing and able to travel to Berkeley, California to meet with Dr. Chiu for your first neurological evaluation? YES or NO
Question 28 of 30
Dr. Chiu works with people in Northern California AND all over the world. Which services are you interested in?
In-Person (Berkeley CA)
Online Consult (Virtual)
Question 29 of 30
Which Program are you applying for?
Initial Modern BrainEVAL
VIP Visit or Retreat
Not sure but would love to learn more
Question 30 of 30
Is there anything else you would like to share?