Session Intake Form

Checkbox *

Have you practiced breathwork before?

Yes

No

Medical history

Important note on contraindications: Breathwork can affect blood pressure, CO2 levels, and nervous system responses, so certain health conditions can be contraindicated. Safety is an absolute priority, so please don't leave anything out and ensure you’ve sought proper medical advice when necessary. Please select all that apply, current or past.

Respiratory problems (asthma, COPD, allergies)

Cardiovascular problems (heart disease, hypertension, heart attack history)

Seizure disorders (epilepsy, seizures, fainting)

History of deep vein thrombosis (blood clots)

High blood pressure

Pregnancy

Glaucoma or detached retina

Bipolar or schizophrenia

Brain or abdomen aneurysm

Anemia

Cancer

Arthritis, osteoarthritis or osteoporosis

Fibromyalgia

Uncontrolled diabetes or thyroid condition

Recent surgeries or physical injuries

Consent and acknowledgement *

I confirm that I have provided accurate health information in regards to any medical, psychiatric or physical conditions which would impair or affect my ability to engage in activities that involve intense physical and/or emotional release. I understand the potential risks associated with breathwork sessions. I agree to inform the facilitator of any discomfort during the session and know that I can withdraw at any time. I acknowledge that these sessions are not a substitute for medical, psychological, or psychiatric treatment or diagnosis, and that the facilitator is not a licensed medical or mental health professional. By ticking "Yes" below I voluntarily agree to participate in these breathwork sessions and hereby release the practitioner from any and all liability.

Yes