Before we breathe together

A 3-minute check-in before your online breathwork session with Ben Ballinger. Breathwork shifts your CO2 levels, heart rate and nervous system state fast. If anything here applies to you, I won't exclude you. I'll modify your breath so you can take part safely.

First Name *

Last Name *

Where will you be during the session? (suburb/city and country, so I can call emergency services if ever needed) *

Phone *

Email *

Your emergency contact: their relationship to you *

Emergency Contact Name *

Emergency Contact Mobile *

Waiver & agreement

Please read before the session. By taking part in this online breathwork session with Ben Ballinger of Primal Breath & Coaching ("Primal Breath"), I agree to the following.

What breathwork involves. Breathwork changes your breathing pattern to shift your physiology and nervous system state. It can bring up strong physical sensations and emotions, like tingling, light-headedness, muscle tightness, temperature changes or emotional release. These usually settle when breathing returns to normal. It is not medical or psychological treatment and doesn't replace it.

My health. I've answered the health questions honestly and fully. I'll tell Ben before the session if anything changes, and I'll follow any breath modifications he gives me.

Looking after myself. I'm responsible for my own experience. I can slow down, return to normal breathing or stop at any time, and I'll do so if I feel unwell. I'll seek medical help if I experience chest pain, a severe headache, fainting or any symptom that concerns me.

Online participation. I'll take part from a safe, private space where I can lie down or sit back, and not while driving, operating anything, or under the influence of alcohol or drugs. Because the session is online, Ben can't physically help me, so I'm responsible for my own physical safety during and after the session.

Risks. I understand taking part carries inherent risks, including physical discomfort, emotional distress and the possible flare-up of existing conditions. I take part voluntarily and accept those risks. I'm 18 or older.

Release of liability. To the extent permitted by law, I release Ben Ballinger, Primal Breath and the community hosting this session from any claim for loss, damage or injury arising from my participation, except where caused by their negligence. Nothing in this waiver excludes rights I have under the Australian Consumer Law that can't be excluded.

Emergencies. If Ben believes I need urgent help, I authorise him to contact emergency services and my emergency contact. Any treatment costs are mine.

Privacy. My health information is collected only to keep me safe in this session. It's stored securely and not shared with the host community or anyone else without my consent, except emergency services if needed for my safety.

Health check: tick anything that applies so I can adjust your breath and keep you safe *

If you ticked anything, tell me more (what it is, how it's managed, anything that helps me adjust for you)

Any current medications?

Anything else on your mind or body I should know? (e.g. recent loss, big life stress, past breathwork experiences)

Your online setup: please confirm each of these *

I'll be in a private, safe space where I can lie down or sit back

I won't be driving, cooking or operating anything during the session

I won't be under the influence of alcohol or recreational drugs

My phone will be within reach

Stay in touch (optional)

Send me occasional emails about Primal Breath sessions and events (unsubscribe anytime)

Health information consent *

I consent to Ben Ballinger collecting my health information to keep me safe in this session

I've read and agree to the Waiver & Agreement above.

Your signature *

Clear