Apply for a Consultation

Thank you for your interest. Please answer the following questions
and we will be in touch regarding the next steps.

Today's Date (mm / dd / yyyy)

First Name

Last Name

Phone Number

State or Province

Country

Are you between the ages of 35 and 65?

Yes

Date of Birth (mm / dd / yyyy)

Gender:

Female

Male

Reason for consultation request:

I'm experiencing brain fog and/or cognitive decline

I have a family history or genetic predisposition to Alzheimer's Disease

I want to prevent cognitive decline and/or Alzheimer's Disease

I want to optimize my brain health and cognitive vitality

I am interested in a Corporate Wellness Program

I have a speaking/media Request

Other

Please describe your brain health concerns and your goals.

Why is reversing cognitive decline and/or optimizing your cognitive vitality important to you?

Are you willing to change your lifestyle and habits (nutrition, sleep, work, stress, ways you think and spend your time)?

YES

What are you willing to do to avoid getting Alzheimer's Disease or other Neurodegenerative Diseases?

How did you hear about Palm Beach Brain Center or our Cognitive Vitality Program?

Message

NOTE: While we welcome all consultation requests, we are a private health company in high demand and respectfully cannot work with everyone. We choose to only work with women who are fully committed to high performance.

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