First Name
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Last Name
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Email
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Phone
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1. What is your primary reason for considering our brain optimization program?
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Enhance work performance
Improve emotional regulation
Increase creativity and problem-solving abilities
Address past trauma or unresolved emotional issues
Other (please specify)
2. On a scale of 1-10, how significantly do you feel your current brain performance impacts your overall quality of life?
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3. Which of the following challenges do you experience regularly? (Select all that apply)
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Difficulty focusing or concentrating
Trouble keeping up with work demands
Emotional reactivity or mood swings
Mental fatigue or brain fog
Rumination on past events or future anxieties
Sleep issues
Other (please specify)
4. Have you tried any of the following methods to address these challenges? (Select all that apply)
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Meditation or mindfulness practices
Therapy or counseling
Medication
Executive coaching
Other brain training programs
None of the above
5. Have you experienced any significant life events or traumas that you feel are still affecting you today?
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Yes
No
Prefer not to say
6. What is your annual income range?
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Under $100,000
$100,000 - $250,000
$250,000 - $500,000
$500,000 - $1 million
Over $1 million
7. Have you invested in personal development or executive training programs before?
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Yes, up to $10,000
Yes, $10,000 - $50,000
Yes, over $50,000
This might be my first investment in this area
8. What's the best way for us to contact you to discuss your application further?
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Phone
Video call
Schedule Your Breakthrough Call
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