Team Member Survey

Please complete this form each time you administer NuCalm on yourself or a fellow team member.
It should be completed by the person who administered the NuCalm session.
Doctor's Last Name*
City*
Person Administering NuCalm
Admin First Name*
Last Initial*
Best Email
If you would like a confirmation of the survey submission, please enter your email address.
Person Receiving NuCalm
Recipient First Name*
Last Initial*
Recipient Role*
Date of Session*
Time of Session
: HH
MM
Actual duration*
How many minutes the session actually lasted
Perceived duration*
How many minutes the person said they thought the NuCalm session lasted
Comments or Questions: *
Please give a description of the session and include any comments, things you noticed and any questions you have about administering NuCalm. If you need immediate assistance, please call (913) 871-0678 M-F 9am-5pm Central.
Thank you for participating in the survey. Please click the 'Submit' button to send to NuCalm

Password Reset

Please enter your e-mail address. You will receive a new password via e-mail.