Name
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First Name
Last Name
Date of Birth
MM
DD
YYYY
Phone
Country
(###)
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Email
*
Please select what type of session interests you most right now (Select only 1):
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What Payment option would you prefer? Details can be discussed further according to the Breathwork Package that you have chosen. (Please Select only 1)
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What made you interested in breathwork?
(Anything specific, either positive or negative that is present for you right now)
Please specify if there is anything in particular you are looking to work through
(Physical, Mental, Emotional, Spiritual)
Contraindications to breathwork. Do you have any of the below contraindications?
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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, or it might be that we just need awareness around your specific needs and we may be able to find an alternative, 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.
If you answered yes to the above or are currently taking any medication, please provide further comment:
Anything else you want to share?
