Am I a Candidate

1

Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

3

E-mail* This field is required.

example@example.com

4

What brings you to Just The Drip today?** This field is required.

Recover from trauma

Enhance mental clarity

Discover relaxation and tranquility

Boost my self-confidence

Strengthen my relationship with myself

Enhance my connections with others

Better manage stress

Assist me in finding my purpose

5

Which Just The Drip service are you most interested in?* This field is required.

In-Clinic Transfusion

At-Home Concierge

Self-Administered , at home treatment

6

Are you experiencing any of the following challenges?* This field is required.

Feeling unmotivated

Persistent negative self talk

Experiencing low energy levels

Difficult maintaining focus

Struggling with poor sleep quality

Constantly worrying

Suffering from chronic pain syndromes

Engage in obsessive thinking

None of the above

7

Are you currently taking or have you previously been prescribed medication for:* This field is required.

Depression

Anxiety

Both

Neither

Engage in obsessive thinking

None of the above

9

Do any of these situations apply to you?* This field is required.