JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Neuroscience Retreat
Survey to explore interest in a Neuroscience Retreat Program
* Indicates required question
Email
*
Your email
Name
Your answer
Would you be interested in
A program for you only
A program that you attend with your child/children (and other caregiver if desired/applicable)
A program that is for your organization/company exclusively
Which format would you consider attending? (check all that apply)
In-person
Online
Which format would you prefer (online or in-person)?
Your answer
How many days would you consider attending an in-person retreat?
1 full day
2 full days (Sat-Sun, community dinner on Sat)
3 full days (Fri-Sat-Sun, community dinner on Fri & Sat)
Other option (please email me)
What is a challenge, goal or desire that is most pressing and/or important for you to address that you believe attending a Mindset Neuroscience training would help with?
Your answer
Any other details I should know?
Your answer
Click yes if you'd like me to email you with updates
*
Yes
No
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Mindset Neuroscience.
Report Abuse
Forms
