Name
*
First Name
Last Name
Preferred Pronouns:
Email
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
*
MM
DD
YYYY
Emergency Contact (Name, Phone Number, and Relationship)
*
Have you previously experienced "conscious connected" styles of breathwork?
*
If so, please provide some basic context, including format (in-person or online, group or private session), duration of the breathing session, and facilitator name/school.
*
Do you have prior experience with “expanded state” journeys and therapies, including but not limited to deep meditation or psychedelics (LSD, Ayahuasca, Psilocybin, MDMA, DMT, etc.)? If yes, please describe briefly, or, we can discuss in person, if preferred.
*
Conscious connected breathwork can induce strong physiological and psychological states of experience, and some medical conditions are contraindicated or may require modification. Do any of the following conditions apply to you?
*
Have you ever been hospitalized for psychiatric reasons, or diagnosed with any psychiatric conditions? If so, please provide some brief background context.
*
Are there any significant traumatic experiences in your history that might surface in a somatic therapy like breathwork?
*
For in-person sessions, do you have any physical conditions, injuries, or sensitivities that would make it difficult to be reclined on the floor for 60-minutes? If so, please describe briefly.
For in-person sessions, do you have any scent allergies (including essential oil fragrances)?
Is there anything else you'd like me to know as we begin our work together?
*
This could be about your health, your past or anything you currently have going on in your life that might come up in our breathe together
Moon Sign
Just for fun - your moon sign (if you know it)
Intention with our time together
I'd love to hear about what your Intention with your breathe is.