What altered your brain chemistry? Story submission

We're collecting true stories from people all over the world for a passion project titled “Altered My Brain Chemistry” — a collection of moments that permanently changed how you think, feel, or see the world.

These stories can be funny, heartbreaking, beautiful, weird, transformative — anything that truly “altered your brain chemistry.”

You can choose to be anonymous, or be credited by name.

If selected, and if this has a good response your story may be featured in the final publication (print and/or digital).

Please answer as openly and honestly as you feel comfortable. Thank you for being part of this project

Sign in to Google to save your progress. Learn more
What is your name?
 (Write “Anonymous” if you prefer not to be named)
Would you like to be credited with your story?
Clear selection
Where are you from (City, Country)?
What was your role in the story you’re telling?
(e.g. nurse, patient, friend, bystander, parent, victim, teacher, student, firefighter etc.)
Tell us the story that altered your brain chemistry *
What changed in you afterward?
(How did this story affect your thinking, emotions, relationships, beliefs, habits?)
What emotion would you say best captures your story?
Clear selection

Do you give permission for your story to be published in the book “Altered My Brain Chemistry”, with possible minor edits for length or clarity?

 *
If selected, your story may appear in print and/or digital formats. You retain ownership of your story, and we will never sell your name or personal information.
By submitting this form, I confirm that the story is true to the best of my knowledge, and that I have the right to share it publicly. *
Required
Email address (optional, in case we need to follow up or send you a free copy of this project moves forward)
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms