What type of account are you looking for?*

What type of reprogramer are you looking for?*

What is your gender identity?*

How do you identify?*

What is your relationship status?*

How important is religion in your life?*

Which religion do you identify with?*

Do you consider yourself to be spiritual?*

Have you ever been in reprogramming before?*

What led you to consider reprogramming today?*

What are your expectations from your reprogramer?*

Would you prefer a reprogramer who is gentle or direct?*

Would you prefer a reprogramer who is flexible or structured?*

Would you prefer a reprogramer who is casual or formal?*

How would you rate your current physical health?*

How would you rate your current eating habits?*

Are you currently experiencing overwhelming sadness, grief, or depression?*

What type of reprogrammer you would prefer?*

Little interest or pleasure in doing things*

Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual.*

Feeling down, depressed or hopeless*

Trouble falling asleep, staying asleep, or sleeping too much*

Feeling tired or having little energy*

Poor appetite or overeating*

Feeling bad about yourself - or that you are a failure or have let yourself or your family down*

Trouble concentrating on things, such as reading the newspaper or watching television.*

Thoughts that you would be better off dead or of hurting yourself in some way*

How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*

Are you currently employed?*

Do you have any problems or worries about intimacy?*

How often do you drink alcohol?*

When was the last time you thought about suicide?*

Are you currently experiencing anxiety, panic attacks or have any phobias?*

Are you currently taking any medication?*

Are you currently experiencing any chronic pain?*

How would you rate your current financial status?*

How would you rate your current sleeping habits?*

Which of the following resources would be useful for you?*

How do you prefer to communicate with your reprogrammer?*

Are there any specific preferences for your reprogrammer?*

Who referred you to ReMaME?*

Please mark all that apply*

I prefer a reprogramer with experience in…*

You can select multiple focus areas as per your convenience

You can select multiple focus areas as per your convenience

Additional focus areas I prefer*