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BrainSAVE! 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 30

Patient's First Name

Question 3 of 30

Patient's Last Name

Question 4 of 30

Contact Person's Name - Relationship to Patient

Put 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)

(Select all that apply)
A

Anytime

B

Morning (8am - 12pm)

C

Afternoon (12pm - 4 pm)

D

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)

PART II – Your Health Goal

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

Question 13 of 30

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

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?

PART III – Readiness Assessment

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)

A

1

B

2

C

3

D

4

E

5

Question 22 of 30

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 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)

A

1

B

2

C

3

D

4

E

5

Question 24 of 30

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 25 of 30

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 26 of 30

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 27 of 30

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 28 of 30

Dr. Chiu works with people in Northern California AND all over the world. Which services are you interested in?

(Select all that apply)
A

In-Person (Berkeley CA)

B

Online Consult (Virtual)

Question 29 of 30

Which Program are you applying for?

(Select all that apply)
A

Initial Modern BrainEVAL

B

BrainCAMP!

C

VIP Visit or Retreat

D

Not sure but would love to learn more

Question 30 of 30

Is there anything else you would like to share?

Confirm and Submit