Name

First Name

Last Name

Phone Number

Provide your country code if your contact number is other than the United States.

Country

(###)

###

####

What are the specific issues you want to immediately address?

Issue #1

Issue #2

Issue #3

What would you most like to alter or change about yourself?

Are you familiar with mindfulness practice or meditation? If so, in what forms?

On a scale of 1-10 (10 = very), how satisfied do you feel with your current work?

On a scale of 1-10 (10 = very), how satisfied do you feel with your professional relationships?

On a scale of 1-10 (10 = very), how satisfied do you feel with your personal relationships?

On average, what percentage of time per day do you feel anxious or frustrated?

What percentage of time per day do you feel sad, lonely, or depressed?

What percentage of time per day do you feel calm or happy?

What else would you like to share with me about your life, your goals, your dreams, or your problems?

Please list 3 potential days or the week and times for Dr. Andrea to respond to your inquiry, based on Pacific Standard Time 6am-midnight in Seattle, Washington, USA https://www.worldtimebuddy.com/

1. Day or Week and the time block you are available to be contacted.

2. Day or Week and the time block you are available to be contacted.

3. Day or Week and the time block you are available to be contacted.

How did you hear about Dr. A? (Check all that apply)

Dr. A’s Radio Show Conversation Re-imagined

Dr. A’s Online Webinar

Dr. A’s Website

Heard Dr. A speak, where?

Heard her on someone else’s podcast or online activity, whose?

Referral from a colleague or friend

Other: (Please answer below)

Other Answer

NeuroCoach is not a medical program, and Dr. Andrea can not and does not guarantee results. NeuroCoach and Dr. Andrea do not provide medical advice. NeuroCoach is not a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or qualified health care provider with any questions you may have regarding a medical condition or treatment or before undertaking a new health care regimen. Never ignore professional medical advice because of something you have heard Dr. Andrea say or you have read on this website. If you have a medical emergency, or are having a mental health crisis or breakdown, immediately call your doctor or dial 911.

Training Or Facilitation