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HOPE Personal Assessment

Personal Brain Assessment

Current & Receint Treatments

A Deep Brain Stimulator implant

Recent surgery, Botox injections, counseling, therapies, or modalities, like massage, chiropractor, acupressure, acupuncture, brain-based or otherwise, including holistic remedies?

Using devices like ECT, EMDR, neurofeedback, biofeedback, and/or listening programs such as the MUSE and binaural beats

Therapist, psychologist, or Psychiatrist (please include medications in details)

Current Treatment Details

Markers of Change I'd like to IMPROVE

Reduce discomfort

Improved Daily Energy Levels

Greater Mood Stability

Better Sleep

More Robust Stress Management

Improved Memory

Faster Problem Solving

Learning More New Things

Improved Sensory performance - vision, hearing, touch, taste & smell

Better Balance

Daily Energy Levels

I have low energy from the moment I wake up

I have energy in the morning but "hit a wall" of fatigue later in the day

I run off of "nervous" energy

I often rely on caffeine or energy drinks to get me through my day

It feels like I have "too much" energy, and I can't stop moving

I often rely on alcohol to help me 'slow down" and 'unwind"

I don't have the energy at the end of the day to do the things I would like to

I have too much energy and often need to be reminded to "slowdown"

I often spend my weekends recovering from the work week.

I often wish I had more sustained energy levels.

Mood Quality & Stability

I struggle with anger & frustration & tend to blame others for life'a struggles

I struggle with sadness & guilt & tend to blame myself for life's struggles

I struggle with strong emotional responses that swing from anger to sadness very quickly

I struggle with low emotional responses and sometimes feel very disconnected from my emotions

I often make decisions based on my emotions or feelings rather than "logic"

I tend to react strongly to my emotions at the moment and often regret my reaction afterwards

I feel I have little to no control over my emotions and emotional responses

I tend to view life from a negative/ pessimistic perspective (anticipating the worst)

I manage my mood with chemicals - medicines, foods, herbals, suppllements.

I often wish my mood was more stable

Sleep:

I don't schedule enough time for sleep

I have difficulty falling asleep

I wake up frequently

I sleep, but I wake up tired.

I sleep, but not as long or deep as I'd like

I am tired, but my mind will not "shut down" and let me rest

I am told I snore at night

I am told I am a restless sleeper

I often wish I had better sleep

I use alcohol, teas, herbals, or other tools to help me sleep

Coping with Stress:

I tend to shut down & retreat when faced with stress or confrontation

I tend to over-react & then regret the way I behaved or reacted later

I tend to hold my fears inside and not talk about them

I tend to express my stress through emotional outbursts

My friends/ family tend to hide from me when I am stressed

When stressed, I tend to hide from my friends/ family

My mind often goes blank in a moment of stress or confrontation

My mind often races in a moment of stress or confrontation

I use alcohol or other substances to cope with stress & relax

I often wish I handled stress better

Thinking Ability/ Cognitive Functions:

I struggle with paying attention or staying focused on a task

I struggle with recall & memory like names, dates & events

I have difficulty creating plans or making decisions

I feel "foggy' or "cloudy" headed

I have difficulty retaing the information that I have read and often have to re-read something several times to understand it

I have difficulty conceptualizing a plan & breaking it into steps & stages

I often wish my mental abilities were more robust in some capacity

Where I want to experience Improvement (check all that apply)

Personally

With Family & Friends

At School / Work

In Activities & Sports

GOALS (check all that apply & explain as needed)

Peak Performance

Improve Performance

Recovery

Symptom Relief

Other

Please describe how you experience this

Additional Details:

Name:

Email:

Phone:

Thank you for starting 2023 with a Comprehensive Brain Assessment.

Your next step will be a phone interview to dive deeper into how your health affects your brain.

We will ask about your health history, medicatications and supplements you are taking. You can get a head start by completing the forms here:

We will get back to you as soon as possible

Your HOPE Team

Oops, there was an error sending your message.
Please try again later

Venice Sullivan

Founder HOPE Wellness Institute
Navy Veteran
Neuromuscular Therapist
Owner Fair Oaks Cereset

Call (916) 965-6558

HOPE Wellness Institute

9801 Fair Oaks Blvd. Suite 200

Fair Oaks, CA 95628

Anxiety
Autism
Car Accident
Concussion
Depression
Divorce
First Responders
Focus
Memory
PTSD
Sleep
Sports Injury
Stress

We do not prescribe or suggest changing any medicines, herbs and/or supplements others prescribe. We do expect clients closely monitor with your prescriber all prescriptions during and for at least 6 months following your work at HOPE and adjust them appropriately. Symptomatic changes and diagnostic changes do not necessarily occur in unison and either can precede the other. Both are observed following sessions. So work with your prescriber and track it.