Information Form Contact InfoFirst Name *Last NamePhone *Street Address *CityState/ProvinceCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweYour Time Zone (for scheduling appointments) *General InfoDate of Birth *MonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212521242123212221212120211921182117211621152114211321122111211021092108210721062105210421032102210121002099209820972096209520942093209220912090208920882087208620852084208320822081208020792078207720762075207420732072207120702069206820672066206520642063206220612060205920582057205620552054205320522051205020492048204720462045204420432042204120402039203820372036203520342033203220312030202920282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925Your gender identification and your preferred pronouns: *EthnicityAsianBlackHispanicWhiteotherMarital StatussingledatingengagedmarriedseparateddivorcedwidowedOccupation or Student InfoEmergency Contact InfoName *Email Address *Phone *Relation *Statements of Understanding - Please read each thoroughly and initial eachto indicate you acknowledge and understand.I understand Wendy Price / Mobile Brain Repair will NOT be providing medical advice, legal advice, psychotherapy, psychology, social work, or counseling, no matter of background, education, training, or licensure. What is offered during Mobile Brain Repair events/meetings is a philosophical approach involving perspective, concepts, processes, and techniques to maximize physical and emotional wellbeing. *I understand no records kept would be of any value in legal proceedings nor would any impressions be of value to health professionals or mental health professionals. Wendy Price / Mobile Brain Repair will NOT provide written or verbal reports to attorneys, health professionals, mental health professionals, health insurance companies, or anyone else. *I understand I am advised to consult with a medical doctor regarding mental illness, drug or alcohol dependency, anxiety, depression, sleep problems, pain, eating disorders, or any other medical issue before making changes in exercise, diet, medication, drug, or alcohol usage. *I understand Mobile Brain Repair meetings will be conducted via Zoom (unless otherwise stated), and that: (1) I will provide all of my equipment (i.e., internet access, webcam, computer, etc.); (2) Communicating via the Internet is not 100% secure; and (3) Wendy Price / Mobile Brain Repair will not be held responsible in the event any outside party passes the video service provider's security and discovers personal or confidential information. *I understand Mobile Brain Repair meetings are not for crisis or emergency situations. If I am considering hurting myself or someone else, I am advised to immediately go to a local mental health hospital or facility or call 911 (emergency dispatchers - US) or 988 (suicide and crisis lifeline - US) for help.I understand when there is reasonable suspicion or report of child, dependent, or elder abuse or neglect; or when someone presents a danger to self or others, that information may be provided to authorities. *I understand payment is made in full prior to meeting, and that any cancellation or rescheduling must take place at least 24 hours prior to meeting start time. *I understand all meetings are video or audio recorded. *It will be assumed communication is acceptable via phone, voicemail, texting, mail, and email unless otherwise indicated here. *Meeting with WendyWhat are you looking to address during your Mobile Brain Repair meeting? *How will your life be affected by the desired update? *OtherHow did you hear about Wendy / Mobile Brain Repair? *referred by someoneI am an existing or prior clientemailinternet searchMobile Brain Repair websiteFacebookInstagramLinkedInOtherIf you were referred, I would love to send a note of gratitude to the person who referred you. Can you please provide their name and mailing address? Would you like your name mentioned in the note?Is there anything else you would like me to know?Is it ok to add you to the email newsletter list? (I promise not to bombard your inbox...you will hear from me just occasionally) *YesNoEnter your full name below as your electronic signature. *Date *MonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212521242123212221212120211921182117211621152114211321122111211021092108210721062105210421032102210121002099209820972096209520942093209220912090208920882087208620852084208320822081208020792078207720762075207420732072207120702069206820672066206520642063206220612060205920582057205620552054205320522051205020492048204720462045204420432042204120402039203820372036203520342033203220312030202920282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925Submit