Breathwork Client Intake From Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Email * Contact Number * Country (###) ### #### Emergency Contact Number * Country (###) ### #### Have you practised any forms of breathwork before? * Yes No If yes, please describe your experience. Do you have any medical conditions or physical injuries that I should be aware of? * (e.g., asthma, heart conditions, high blood pressure, epilepsy) Yes No If yes, please list them. Are you currently taking any medications? * Yes No If yes, please list them. Do you have any history of mental health conditions, including anxiety, depression, or trauma-related experiences? * Have you ever experienced dizziness, fainting, or hyperventilation? * Do you have any respiratory conditions or sensitivities? * (e.g., chronic bronchitis, allergies) Are you currently pregnant or trying to conceive? * Yes No What are your main goals for these sessions? * (e.g., stress relief, emotional release, clarity, relaxation) Do you have any specific challenges or areas of focus you’d like to address? * (e.g., grief, anxiety, physical tension) How would you describe your current emotional state? * (e.g., calm, stressed, overwhelmed, balanced) Are there any specific triggers or sensitivities I should be aware of during our sessions? * Do you feel comfortable with physical adjustments or energetic touch? * Yes No Do you have any accessibility needs or special requests to ensure your comfort during the session? * Yes No If yes, please state. Please share anything else that will help me prepare for our time together. Do you consent to participate in these breathwork sessions, acknowledging that they are not a substitute for medical advice or therapy? * Yes No Preferred date for first session: MM DD YYYY I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in this session. * I AGREE Thank you!We will be in touch soon to confirm your session.