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Breathwork Group Application
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Email
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Your email
Name
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Your answer
Date of Birth
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MM
/
DD
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YYYY
OccupationÂ
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Your answer
Have you done breathwork before? If yes, when and with whom?
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Your answer
Have you participated in group work before?
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Yes
No
Other:
Are you a healing practitioner or therapist?
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Yes
No
Other:
Have you participated in a ceremony or engaged with psychedelics (we don't use them in this space, it is helpful for us to know.)
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Yes
No
Are you pregnant or do you have a chance of being pregnant at this time?
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Yes
No
Other:
Do you take any medications? If yes, which and what doses?
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Your answer
Any health concerns or limitations to somatic work, breathwork, and bodywork?
Your answer
Which Breathwork Group (Month, Year) are you applying for?
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Your answer
Are you willing and able to engage with deep and sometimes intense inner work?
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Yes
No
Other:
What are your intentions or desires for joining this group?
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Your answer
What will you absolutely choose to create in joining this experience?
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Your answer
Where did you hear about working with Rivky?
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Your answer
Is there anything else you would like to share here that pertains to Breathwork?
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Your answer
Send me a copy of my responses.
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