Name
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First Name
Last Name
Email
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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Country
(###)
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What is your date of birth?
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Please list all medications you're currently taking (or if not applicable, simply say "none"):
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Please list any allergies you have (or if not applicable, simply say "none"):
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Are you currently pregnant?
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Please list any mental health conditions you contend with (or if not applicable, simply say "none"):
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Please list any acute or chronic ailments/illnesses you contend with (or if not applicable, simply say "none"):
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Do you give permission for me to apply physical touch during your Breathwork session? If yes, are there any areas you wish for me to avoid or approach carefully? If not, simply say "none."
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What’s drawing you to breathwork at this time in your life?
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Have you done breathwork before? If so, how was the experience for you?
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What was your childhood like?
What are key traumas/hurtles you’ve faced in life, or are currently facing?
What is your relationship with your parents/caregivers like?
Are their experiences from your childhood/teenage years that you are still holding onto, or that currently cause you pain?
How would you describe your mental health history?
Please describe your present-day life—your work, your social life, your relationships, your current state of being:
Please describe your past and present-day relationships with vice and/or addiction?
What gives you joy in life?
Please check below to indicate you've read and agree to the following waiver of liability:
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I hereby affirm that I am voluntarily starting guided sessions in breathwork. I am voluntarily participating in breathwork entirely at my own risk. In full consideration of the risk of injury while participating in breathwork, and for the right to participate in breathwork, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily participate in this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in breathwork, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any kind of risks related to traveling to and from as well as participating in breathwork, which may include, but are not limited to, physical or psychological injury, pain, suffering, illness, temporary or permanent disability, economic or emotional loss, and death. I acknowledge that I have carefully read this form and fully understand that it is a release of liability. I expressly agree to release and discharge the breathwork facilitator from any and all claims or causes of action and I agree to voluntarily give up or waive any right that I may otherwise have to bring a legal action for personal injury or property damage.
Please check below to indicate you've read and agree to the following policies on cancellation, payment, and (re)scheduling:
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All sessions must be paid for in full at the time of their purchase. Sessions must be booked and paid for, by e-transfer, at least 48 hours prior to their servicing. Sessions will only be refunded if a client cancels a minimum of 48 hours in advance of their booking. A client can reschedule a booking at any point outside of the 48 hour cancellation window. If a booking needs to be altered 24-48 hours in advance of a session, a client can change it to a different day, one time, without charge. Any booking cancelled within the 48 hour cancellation window will be charged for in-full.