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Online Application

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!

Start

PART I – Basic Info

Just a few basic questions so we can get to know a bit about you

Question 2 of 25

Name (FIRST, LAST)

Question 3 of 25

Phone number and best time to reach you (Pacific Standard Time)

Question 4 of 25

Location (CITY, STATE, COUNTRY)

Question 5 of 25

Date of Birth (DD/MM/YYYY)

PART II – Your Health Goal

Thanks for completing the first part of your application. Just two more sections to go!

Question 7 of 25

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 8 of 25

Question 9 of 25

Question 10 of 25

If you had a magic wand and could erase three problems, what would they be?

Question 11 of 25

What have you tried so far that HAS worked for you?

Question 12 of 25

Question 13 of 25

How much time would you be willing to invest to overcome your health challenge once and for all?

Question 14 of 25

If you could have one question answered about your health challenge, what would it be?

Question 15 of 25

How did you hear about us?

PART III – Readiness Assessment

Last section– you got this!

Question 17 of 25

How ready/willing are you to significantly modify your diet

(1 = Not Willing and 5= Totally Willing)

A

1

B

2

C

3

D

4

E

5

Question 18 of 25

How ready/willing are you to take nutritional supplements every day

(1 = Not Willing and 5= Totally Willing)

A

1

B

2

C

3

D

4

E

5

Question 19 of 25

How ready/willing are you to modify your lifestyle (i.e. work demands, stress management)

(1 = Not Willing and 5= Totally Willing)

A

1

B

2

C

3

D

4

E

5

Question 20 of 25

How ready/willing are you to practice relaxation techniques

(1 = Not Willing and 5= Totally Willing)

A

1

B

2

C

3

D

4

E

5

Question 21 of 25

How ready/willing are you to engage in regular exercise

(1 = Not Willing and 5= Totally Willing)

A

1

B

2

C

3

D

4

E

5

Question 22 of 25

How ready/willing are you to have periodic lab testing to assess your progress

(1 = Not Willing and 5= Totally Willing)

A

1

B

2

C

3

D

4

E

5

Question 23 of 25

Are you willing and able to travel to Berkeley, California to meet with Dr. Chiu for your first neurological evaluation?

A

YES

B

NO

Question 24 of 25

Which Program are you applying for?

(Select all that apply)
A

Initial Modern BrainEVAL

B

Brain Camp

C

VIP Visit or Retreat

D

Not sure, but would love to learn more

Question 25 of 25

Is there anything else you would like to share?

Confirm and Submit