Not sure where to start? Complete this short form and we’ll review your answers, look at what’s currently affecting you most, and send you a personalised recommendation for your next best step with Re-MIND Institute within 3 business days.

Note: Everything in this form is private and confidential.

Tick below all areas that you would like to seek support for *

In your own words, expand on anything you ticked above, or add anything else you are struggling with. Give as much context as possible. *

Add context here re timing or duration if it is relevant. Otherwise you may leave it blank.

Add context here re impact on yourself, or on others, if it is relevant. Think about what it stops you from doing that you would love to do, or what it makes you do that you would love to stop doing. Otherwise you may leave it blank.

Please enter a number between 1 and 5 in each box to rate each of the following - these give me an indication of the function of the stress centres of your brain: *

General Health (5 is the best)
Energy (5 means you have GREAT energy levels)
Pain (5 represents the WORST pain)
Stress (5 means the highest level of stress)
Sleep quality (5 means the BEST sleep quality)
Sex drive (5 means totally content)

Add context here re what you have tried before. What worked well for you? What didn't? Otherwise you may leave it blank.

Select all statements that are TRUE for you. These help us understand your brain development and sense of self networks during your formative years that can play an enormous role in our adult life. In my early life I consistently felt: *

Imagine we've waved a magic wand and been able to help you overcome your main challenges. What tangible evidence would you be seeing, feeling, or hearing in your life in 6 months time that would indicate that this work has been worth it for you? How would your life be different? *

How soon are you hoping to begin getting support? *

Which investment options feel doable for you right now? Tick all that apply. This helps us recommend a next step that fits both your healing and development needs and your current capacity.

I need free resources or the lowest-cost starting point available

A self-paced program around $397–$497 USD (approx $600-700 AUD) feels manageable - PayPal pay in 4 (approx $100 USD / fortnight for 4x fortnights) is available

1:1 intensive support from $1,500 USD (approx $2,200 AUD) could be realistic if it was the right fit

An intensive live transformational program across a whole year for around $3,500 USD (approx $5,000 AUD) could be realistic if it was the right fit

I am open to an internal payment plan or external finance to access whatever level of support I need

I am not sure yet and would like guidance

Is there anything else you would like us to know before we recommend your next step? If not, you may leave this blank

First Name *

Last Name *

Mobile phone number *

Email *

How did you find out about us? *

I will personally review your responses, and make a recommendation based on your unique set of circumstances within 3 business days. I will send an email with your recommendation, and an SMS notifying you that it is in your inbox in case it gets filtered to a promotions or junk folder. - Dr Ash

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