Share Your Story

We’re looking for people who have been impacted by brain disease to participate in a video. The goal of the video is to raise awareness for all brain diseases and disorders by sharing real stories to show the impact these diseases have on patients and their loved ones.

Please fill out the form below and tell us a little about how brain disease has impacted you. From there, we will schedule a brief conversational interview with you over Zoom to learn more about your story.

Your Name:*
Your Email*
Your Location*
City State / Province / Region ZIP / Postal Code Country
Connection to Brain Disease*
Please share 1-2 sentences about your connection to brain disease.
Are you willing to have a 20-25 minute phone conversation with a Producer to share your story with us?*
- Yes
- No
If chosen to be in the video, are you willing to film in person with a small camera crew following COVID-19 safety guidelines?*
- Yes
- No
What is the best way to reach you?*
- Phone
- Email
Your Phone
Please provide best phone number to reach you.
Phone
This field is for validation purposes and should be left unchanged.