Brain Consultation Client Intake Form
Discovery calls with Cavin are highly discounted at a rate of $50. By submitting this form, you agree to pay the discovery rate ($50 USD) before your scheduled call. You can pay via PayPal to cavin@feedabrain.com, and a receipt will be sent to the email address provided. By submitting this form, you also agree to the following: Any information or advice provided is not intended to replace the services of a physician. Reliance is solely at one's own risk. Cavin Balaster has no formal medical training and his consultations are for informational and emotional support purposes only. Consultations are not a substitute for professional medical advice. Any action on the clients part in response to the information provided is at the clients' discretion.
Email address *
Full Name
Do you have a Skype handle? If yes, add me on Skype (CavinB9), and leave your Skype handle here. If not, write "no" *
What is your phone number? *
Your age *
Loved one's age and location (if applicable)
Loved one's location (if applicable)
Date of Event (if applicable)
MM
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DD
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YYYY
Please explain your situation and why you are reaching out. (please be as detailed as possible) *
What are your hopes as of now? How would you like to see the future? (try to be specific) *
Have you read Cavin's book, How to Feed a Brain? *
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Is there anything else you would like me to know before our conversation?
Please list all medications and supplements being used. Try to be specific with brand names and dosages if possible, but don't let this hold you up (we will go over this on the phone and you can edit this form after submitting). *
Please describe current diet of you and/or your loved one, whichever is applicable (we will go over this on the phone and you can edit this form after submitting). *
Are you prepared to make a significant mental, emotional, and financial investment to bring about the best possible scenario for you and/or your loved one(s)? *
Please upload any photos, videos, or medical records that you'd like me to see (or you can send them to consult@feedabrain.com).
Thank you for your responses. After submitting for you can schedule an appointment using the scheduling link provided. Cavin will then contact you at the scheduled time. Please come with paper and something to write with.
Discovery calls with Cavin are highly discounted at a rate of $50. By submitting this form, you agree to pay the discovery rate ($50 USD) before your scheduled call. You can pay via PayPal to cavin@feedabrain.com, and a receipt will be sent to the email address provided. By submitting this form, you also agree to the following: Any information or advice provided is not intended to replace the services of a physician. Reliance is solely at one's own risk. Cavin Balaster has no formal medical training and his consultations are for informational and emotional support purposes only. Consultations are not a substitute for professional medical advice. Any action on the clients part in response to the information provided is at the clients' discretion.
A copy of your responses will be emailed to the address you provided.
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