How to Vanquish Depression + Beat Anxiety Resource Chat Intake Form

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Please answer the questions below honestly and as completely as possible. Your answers will help guide our conversation, streamlining it so that you get the most of your time. There are no bad answers, only incomplete ones.

Email *

Name *

Bio *

Tell me about yourself. Who are you? Where are you from? Is that important to you? If not, what is? What questions keep you up at night? What are your wildest dreams?

How did you find this class? *

What did you gain from completing it? *

Tell me what really worked for you and/or what most captured your interest.

What questions still linger? *

Where are you feeling stuck? What challenges are you having? What would you like to discuss further during our chat?

Do you have a therapist? *

Yes

Other:

If you have (or think you have) anxiety or depression, what treatments have you already sought? *

Is there anything else you'd like to share in order to guide our conversation? *

Phone Number *

Resource chats will take place via phone. By providing your number you consent to having this conversation via phone. I will not sell, share, or trade your phone number.

How long did you book a session for? *

Half-hour (30 minutes)

One hour (60 minutes)

If I determine that the energy is off and I am unable to help you, I will issue a full refund of your payment. It is not personal, it is energy, therefore an explanation is not always available. *

I have read and understand the above statement. I agree that if the vibes are off, I deserve to have my money returned. I will do my best to not take it personal.

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Jaminnia is not a medical professional, nutritionist, dietitian, or attorney. Content shared on this platform is for informational purposes only. It is not intended to substitute for legal or mechanical advice, or medical treatment or diagnosis, and is not monitored or evaluated by the Food and Drug Administration/FDA. Consult your health care provider if you are experiencing any symptoms and before using any herbal product or beginning a new health regimen. Never disregard professional medical advice or delay in seeking it because of something you have received, read, or heard via this website, courses, one-on-one sessions; or physical and/or digital materials provided by Jaminnia States or Kioni Speaks. By using any or all of this information, you do so at your own risk. No warranties are expressed or implied. Any application of the material provided is at the reader’s discretion and is his or her sole responsibility. *

I have read and understand the above statement. I acknoweledge and understand that this one-on one session is not a substitute for therapy, medical, or legal advice. I agree to hold Jaminnia States & Kioni Speaks harmelss in the event of any displeasing, adverse, or harmful effects connected to these sessions and fully enter into this agreement by centering and honoring my own sound judgement.

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