Breathwork — new client form
If it's your first time or it has been over 6 months practicing with Lewis please take a few moments to complete this form before your session..
All information is strictly confidential and is never shared with anyone without consent.
If you have any questions please email me at lewis@twopalmsbreathwork.com
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Email *
Full Name *
Date of birth
MM
/
DD
/
YYYY
Have you experienced any type of breathwork or other breathing practices before?
Please give a brief overview.
Are you able to lay down for about 1 hour?
If no, please describe. *
Do you have any health issues, including heart issues, or surgery within the past 6 months? (Also any current medication and/or medical or alternative treatments). *
Are you working with any of the following: glaucoma, uncontrolled high blood pressure, cardiovascular issues such as angina, detached retina, previous heart attack or stroke, severe PTSD or trauma, diagnosed aneurysms in the brain or abdomen, uncontrolled thyroid conditions or diabetes, asthma, epilepsy, stomach ulcers, history of bipolar disorder or schizophrenia, or any psychiatric hospitalisation or emotional crisis within the past 10 years?

If yes, please give a specific overview as this may mean a variation on the practice or not being able to participate in the session.
 *
Are you or could you potentially be pregnant?
If yes, please say how far along you are as you will be offered variations or potentially not be suitable to join the session at this time.
 *
Are you currently in therapy and/ or other support groups?
Do you have any questions or concerns or is there anything else that you would like to share that you feel may be helpful in you having a great session?
What upcoming session will you be joining?
Date / time / location
Would you like to be added to the mailing list to find out about upcoming sessions?
 *

I acknowledge that I am voluntarily participating in the breathwork session(s) and I understand that the practice of breathwork may bring up emotions, feelings, and physical sensations that can be intense and potentially uncomfortable. I take full responsibility for my participation in these sessions and any consequences that may arise from them.

I understand that it is my responsibility to communicate any discomfort, pain, or other concerns to one of the facilitators before or during the session(s). I also understand that I am in control and have the right to stop or modify my participation in the session(s) at any time.

I am happy to continue with the upcoming session(s):

 *
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