First Name

Last Name

Email Address

Phone Number

1. How would you like to work with Simone? (Check all that apply) 1. How would you like to work with Simone? (Check all that apply) Concussion Treatment Dynamic Brain Healing Fascia Treatment for Chronic Pain Other (Please specify)

Specify here

2. What are your primary concerns or symptoms? (Check all that apply) 2. What are your primary concerns or symptoms? (Check all that apply) Headaches / Migraines Brain Fog / Memory Issues Anxiety / Depression Sleep Issues Chronic Pain / Injury Post-Concussion Symptoms Athletic Performance & Recovery Other (Please specify)

Specify here

3. Have you been diagnosed with any of the following? (Check all that apply) 3. Have you been diagnosed with any of the following? (Check all that apply) Concussion or Traumatic Brain Injury (TBI) ADHD or Neurodivergence PTSD or Emotional Trauma Chronic Pain Condition (e.g., Fibromyalgia) Autoimmune Condition (e.g., Lyme, MS) Other (Please specify)

Specify here

4. How long have you been experiencing these issues? 4. How long have you been experiencing these issues? Less than 3 months 3-6 months 6 months - 1 year Over a year

5. What have you tried so far for relief? (Check all that apply) 5. What have you tried so far for relief? (Check all that apply) Physical Therapy Chiropractic Medications Supplements / Brain Nutrition Massage Therapy Mindfulness / Meditation Other (Please specify)

Specify here

6. On a scale of 1-10, how committed are you to finding a solution? (1 = Not ready, 10 = Fully committed) 6. On a scale of 1-10, how committed are you to finding a solution? (1 = Not ready, 10 = Fully committed) 1 2 3 4 5 6 7 8 9 10

7. Do you prefer to work with Simone in-person or online? 7. Do you prefer to work with Simone in-person or online? In-Person Online / Virtual Sessions Open to Both

8. Would you be interested in a Brain Health Assessment to personalize your treatment? It is required to work with Simone. 8. Would you be interested in a Brain Health Assessment to personalize your treatment? It is required to work with Simone. Yes, I want to learn more No, I prefer to start with treatment

9. What is the biggest obstacle holding you back from healing? (Open-ended response)

10. Anything else you'd like Simone to know before your consultation? (Open-ended response)