Name * First Name Last Name Birthday * MM DD YYYY Phone * Country (###) ### #### Email * What services are you interested in? Select One Option 1 Session 6 Sessions 12 Sessions Credential Are you currently healthy? * Do you currently use medication for the heart? * No Yes List any allergies you are aware of (food, environmental etc.) Are you pregnant or do you wish to become pregnant? * No Yes Why are you interested in breath? What do you hope to accomplish with your session? Please read the below risks * By clicking the submit button I declare that all the information I provided is true, and I acknowledge that I have been informed of the potential risks associated with breathwork practices. I voluntarily assume full responsibility for any physical, emotional, or psychological effects that may result, and I hereby release and discharge the facilitator and any affiliated parties from any and all liability, claims, or demands arising from my participation. ___________________________________ Contraindications & Safety Breathwork results in specific physiological changes in the body and can result in intense physical and emotional release. As a precaution, the following conditions are contraindicated in certain breathwork practices: Medical Contraindications ● Epilepsy ● Detached Retina ● Glaucoma ● Prior strokes or seizures ● Pregnancy - first trimester only - ok after that ● Asthma (if you have asthma, you can participate, but you must have your inhaler available) Psychiatric Contraindications Prior diagnosis by a health professional of bipolar disorder or schizophrenia Psychotic or borderline psychotic states Any other medical, psychiatric, or physical conditions that would impair or affect the ability to engage in any activities that involve intense physical and/or emotional release. As always, please consult your medical doctor before practicing breathwork. And contact us if you are at all unsure whether one or more of the above apply to you. Safety ● Always practice in a safe environment – either seated or lying down ● Never practice while operating a vehicle ● Never practice while in water or just before jumping into water. Expectations During The Practice You might encounter many feelings or sensations during your breathwork experience. Some may feel awesome, others uncomfortable. Whatever it is, we always like to say perspective is key. Let whatever comes up be a reminder that you are alive and powerful. This is an opportunity to feel that! First and foremost, YOU are always in control of your breath! No matter what may be instructed or demonstrated in a breathing session, you ultimately get to decide how you breathe. You can change the speed, force, and flow of your breath at any point—leaning into the things that are feeling great and pulling back when things feel too much. Any sensations that may arise are only temporary, most due to a change in your internal chemistry. We recommend continuing to breathe but adjusting your breathing where needed. If at any time, you feel like it is too much, just go back to your normal breathing pattern and they will quickly subside. And it's worth saying again... YOU are always the one in control of your breath! Here are some things you may experience (but are not limited to): ✨🌀 Light-headedness ✨Tingling / Buzzing 👂 Ringing in the ears 〰️ Trembling, shaking, or other physical sensations, including spontaneous physical movement 🥱 Yawning 🌡 Temperature change 💥 Muscle cramps / Tetany (particularly in the hands, lips, and feet) 👄 Swallowing 🥹 Emotional experiencing, release, and catharsis I acknowledge and understand the risks Thank you for your submission. We will get back to your shortly.FERAL STATE
