9D Breathwork 6 Week Course

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

9D Breathwork 6 Week Course - Level 1

Self-Assessment & Suitability Questionnaire

Thank you for your interest in joining our 6 - week 9D Breathwork journey.
This questionnaire helps us understand where you’re at, what support you need and whether this container is the right fit for you right now.

Confidentiality: Your answers are kept confidential and used only for screening + supporting your experience.
Time: ~8–12 minutes.

Your Details

Full Name *

Email *

Phone Number *

Age *

Emergency Contact Name *

Emergency Contact Number *

Current Baseline

Rate the following (1–10):

Current stress levels
*

Not Stressed

Extremely Stressed

Sleep quality (past month)
*

Terrible

Like A Baby

Mental Clarity
*

Can't see through the fog

I know Kung Fu

Energy levels across a typical day
*

Sloth

Malinois (very energetic dog)

Ability to stay calm under pressure
*

I cannot

What is pressure?

Ability to focus without being pulled into worry
*

I'm worried right now

I can focus good

How supported do you feel in your life right now?
*

Not at all supported

I have a great support system

How resourced do you feel to meet your day-to-day life?
*

I forgot my shoes

I'm ready for anything!

What’s Creating Pressure Right Now?

What contributes most to your stress? (you can use % if helpful)

Work/Career
*

Relationships
*

Family/Parenting
*

Financial
*

Health
*

Home/Environment
*

Identity/Meaning/Purpose
*

Other
*

How does stress typically show up in your body? (tick all that apply)
*

Headaches/migraines

Tight chest/shortness of breath

Muscle tension/neck/shoulders

Digestive issues

Fatigue/burnout

Insomnia/light sleep/waking often

Anxiety/panic sensations

Low mood/tearfulness

Irritability/anger

Numbness/shutdown/dissociation

Other (please describe)

Required

Description *

Have you ever been diagnosed with, or experienced, any of the following? (tick all that apply)
*

Panic attacks

PTSD / complex trauma

Depression

Anxiety disorder

Bipolar disorder

Psychosis / schizophrenia

Dissociation / depersonalisation

Eating disorder

Substance dependency

Other (please describe)

None of the above

Required

Description *

Please tick any that apply (current or recent):
*

Heart condition (including history of heart attack/angina/arrhythmia)

Uncontrolled high blood pressure

Stroke / aneurysm history

Epilepsy / seizures

Glaucoma or retinal detachment

Severe asthma / breathing disorder

COPD or serious respiratory condition

Fainting episodes / unexplained blackouts

Recent surgery (past 3 months)

Severe osteoporosis

Pregnancy (current)

Other significant medical condition (please comment below)

None of the above

Required

Consent + Agreements

I understand breathwork can be emotionally and physically intense and may bring up sensations, memories, or strong feelings.
*

I do

Required

I agree to take full responsibility for my wellbeing, and to communicate if I feel overwhelmed, dizzy, unsafe, or need support.
*

I do

Required

I understand this course is not a substitute for medical or mental health treatment.
*

I do

Required

I confirm the information I’ve provided is accurate to the best of my knowledge.
*

I do

Required

I consent to being contacted about my application and course details.
*

I do

Required

Thank You

Thanks for filling out this form and we look forward to getting in touch soon.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms