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 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)
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
Briefly, what is your health goal?
Question 9 of 25
What is your biggest frustration in reaching your health goal?
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
What have you tried so far that HASN'T worked for you?
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?
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)
Question 18 of 25
How ready/willing are you to take nutritional supplements every day
Question 19 of 25
How ready/willing are you to modify your lifestyle (i.e. work demands, stress management)
Question 20 of 25
How ready/willing are you to practice relaxation techniques
Question 21 of 25
How ready/willing are you to engage in regular exercise
Question 22 of 25
How ready/willing are you to have periodic lab testing to assess your progress
Question 23 of 25
Are you willing and able to travel to Berkeley, California to meet with Dr. Chiu for your first neurological evaluation?
Question 24 of 25
Which Program are you applying for?
Initial Modern BrainEVAL
VIP Visit or Retreat
Not sure, but would love to learn more
Question 25 of 25
Is there anything else you would like to share?