Work with me

Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone *

Country

(###)

###

####

Please select how you would like to work with me: You are welcome to select more than one option.

Single Session

Couple Session

Breath Alchemy: 2 Month Package

Breath Alchemy: 4 Month Package

Journey to Wholeness: Connected Group Breathwork

What Payment option would you prefer? Details can be discussed further according to the Breathwork Package that you have chosen.

Once-off Full Payment

Fortnightly Payments from date of booking (Includes 5% admin fee)

Contraindications to breathwork. Do you have any of the below contraindications?

There are some contraindications to activated breathwork. If you any of the following applies to you, an activated breathwork journey may not be suitable for you, however we may be able to find an alternative in some cases, so please specify and we can discuss further. - Pregnancy. - A personal or family history of epilepsy, seizures, cardiovascular problems including angina or heart attacks, high blood pressure, aneurysms, glaucoma, retinal detachment, osteoporosis, or recent physical injuries, surgery or illness - particularly involving the brain, mouth, teeth, nose, throat, thyroid, immune system, lymphatic system, lungs, chest, ribs, spine, neck and/or reproductive organs. - Some medication (please list in the next question). - A personal history of serious mental illness, personality disorders, hospitalisation for any psychiatric condition or emotional crisis, suicidality, psychosis or a current drug/alcohol addiction.

YES

NO

A breathwork journey involves conscious connected deep breathing through the mouth, and restorative breathing through the nose. Are you able to breathe using these techniques? *

YES

NO