I'm really looking forward to connecting with you and supporting you on your journey. To ensure we make the most of our time together, and for your safety, I kindly ask you to complete this New Client Online Intake Form before our first session. This form gathers essential information about your health, lifestyle, and what you hope to achieve through breathwork, allowing me to tailor our sessions specifically to your needs. If you have any questions as you're filling it out, please don't hesitate to reach out.

First Name *

Last Name *

Email *

Phone *

Preferred Communication Channel

Date of birth *

Are you regularly taking any prescription medication and or natural supplements. Please give as much detail as possible *

Please provide your exact diagnosis

Are you currently pregnant or believe you may be pregnant?

Yes

Do you currently smoke, vape, or use nicotine products?

Yes

What type of experience are you attending? *

Deeper Reflection & Nervous System Awareness

On a scale of 1-10, how would you rate your current stress levels?

Please explain what contributes most to your stress rating (e.g. Family pressure and work demands Work/Career: __% Relationships: __%, Financial: __% Health: __%, etc.

What’s your biggest challenge that you’re facing day-to-day?

How does stress typically manifest in your body? (e.g., headaches, muscle tension, sleep issues)

How effective are you at managing your stress on a scale 1-10? .

How would you describe your energy levels throughout a typical day?

When you feel stressed or out of alignment, what is your default coping response?

Which of the following best reflects your sleep quality?

How would you rate your mental clarity?

When was the last time you felt truly relaxed, and what were you doing?

Do you have a reliable way to decompress after a stressful day or event?

Yes — something that genuinely helps

Sometimes — but not consistently

No — I usually carry it with me

Do you have at least one person you can openly discuss your stress with?

Do you have daily practices that help you stay grounded?

How open do you feel to deeper nervous system and emotional work right now?

How safe does your body currently feel on a day-to-day basis? (1–10)

What would feeling more aligned, calm, or empowered in your life actually look like for you?

Session Intentions & Comfort

What drew you to the idea of breathwork?

What are your expectations for your breathwork journey?

Do you have any allergies (Environmental or Consumable)

Are there any sounds, scents, or experiences that you love?

What support helps you feel safest during emotional experiences?

Have you ever been in a situation where you were unable to breathe such as near-drowning, suffocation, being trapped, or having your breath restricted against your will?

Would you like to receive a short post-session grounding/integration audio?

Yes

Important Participation Acknowledgment

By signing below, you acknowledge that:

Breathwork may involve intense physical, emotional, and psychological experiences
You have disclosed all relevant medical and mental health information
You understand participation is voluntary and undertaken at your own risk
You agree to notify Breath Vortex of any future changes to your medical, psychological, or physical condition
You understand this agreement applies to all current and future Breath Vortex services unless otherwise updated in writing
You consent to the electronic signing and processing of this form
You have read and agree to the full Terms of Service, Liability Waiver, and Privacy Policy

I agree to the Terms of Service
I agree to thePrivacy Policy
I consent to electronic signature and communication
I understand this waiver applies to current and future Breath Vortex services

Electronic Signature (REQUIRED BELOW) *

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