Breathwork — new client form
If it's your first time practicing with us, please take a few moments to complete this form before your first session (it shouldn't take more than 5 minutes).
All information is strictly confidential and is never shared with anyone without consent.
If you have any questions please email lewis@twopalmsbreathwork.com
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Email *
Full Name *
Date of birth
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DD
/
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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 50 minutes?
If no, please describe. *
Do you have any health issues, including heart issues?
(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 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.
*
Are you currently in therapy and/ or other support groups?
Is there anything else that you would like to share that you feel may be helpful in you having a great session?
Do you have any questions or concerns about participating in this work?
What upcoming session will you be joining?
Emergency contact information (Optional)
Please provide name, relationship to you, phone number
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):

 *
If you have any queries or questions please email lewis@twopalmsbreathwork.com
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