How are we doing?

* Name:

* Email Address:

* Which service did you sign up for?

Neurology 101 (for athletes)

Neurology 101 Intensive Coaching

Functional Diagnostic Nutrition

Personal Training

Other

* Why did you sign up? What is your primary goal or desired outcome?

How would you rate the following:

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
* You feel your Coach clearly understands what is important to you, your goals and your desired outcome

* You feel your coach cares about you, your progress & outcome and your experience at Brain Based Fitness

* You understand the exercises you are expected to perform on your own, how often and when and how to do them

* You feel confident doing the exercises on your own ("homework")

* Regarding "homework", you feel you are able to complete most of the prescribed reps and sets on most days

* You feel you understand enough of the "why" regarding your neurological function to know HOW the exercises assigned to you will help you achieve your goals or desired outcome

* You feel you are making progress towards your goals or desired outcome

* You feel confident you will achieve your goals or desired outcome with the help of the Brain Based Fitness team

* You feel you are treated with respect during each interaction with Brain Based Fitness Team

* Brain Based Fitness team members act professionally

Is there anything we can do to improve?

Is there anything we are NOT doing that you feel would help you?

Are you to to refer us to a friend?

Willing to Refer

Not Yet

Is there anyone you know who may benefit from our services?

Yes

No

If so, would you be willing to ask them for their permission for us to contact them and invite them to a free consultation?

Yes

No