First Name

Last Name

Email *

Phone *

Date of birth

Stress I feel that I am in complete harmony with my stress levels. There isn't much that knocks me off my center.

Not at all true

Not quite true

Mosty true

Completely true

Anxiety - I don't have any issues with anxiety. I always feel completely calm, relaxed and at ease.

Not At All True

Not Quite True

Mostly True

Completely True

Have you ever experienced a guided breathwork journey before? (a minimum of one hour)

What inspired you to try a breathwork session? What are you hoping to achieve?*

What are the top 3 things you're struggling with in your life at the moment?*

Do you have any of the following medical conditions? Currently on Heavy Medication, Severe Psychiatric Symptoms, Bipolar Depression, Osteoporosis, Asthma, Experiencing Emotional or Spiritual Crisis, Cardiovascular Problems, High Heart Rate or Blood Pressure, History of Epilepsy or Seizures, History of Diagnosed Mental Health Issues*

Yes (If yes please explain in the box below)

If you answered the contraindications yes, please explain here

Do you feel capable of processing any old traumas or unintegrated suppressed emotional stuff that may come up in the session?

Yes, I am ready to get out the way.

I am not sure if I am ready to face it.

This question scares me.

Is there anything else you feel I should know going into our session together? OR Are there any questions you would like to ask in advance?

PLEASE READ THIS AND WRITE YOUR FULL NAME IN THE BOX PROVIDED BELOW THIS TEXT TO CONFIRM> Breathwork Liability Waiver Form Template I/we prioritise the safety and well-being of all our participants, and as part of our commitment to ensuring a secure environment, we require the completion of this Liability Waiver Form.A breathing session may not be suitable for you if you have the following conditions:Cardiovascular problems, abnormally high blood pressure, aneurysms, epilepsy and seizures in the past, anyone taking heavy medication, severe psychiatric symptoms especially psychosis or paranoia, bipolar, osteoporosis, recent surgery, glaucoma or is currently pregnant. People with asthma should bring their own inhaler and consult with their physician and breathing session instructor before participating. Anyone experiencing an emotional or spiritual crisis or any person with a mental illness who is not in treatment or lacks adequate support. Please note, this list is not exhaustive and we generally advise that if you have a question about a condition you may have that is not listed here, you consult a physician before participating in these breathing sessions. I warrant and represent that I am in good health physically, mentally, psychologically and emotionally, and I understand and warrant that if I am not in good health I will not be allowed to perform the activities and sessions. Accordingly, the declaration and certification that I am in good health in all the above-mentioned respects constitutes a material agreement to allow me to participate in the breathing sessions. I know and acknowledge that the person facilitating is not a doctor or psychiatrist, or a specialist in health care, and that the activities offered are not intended to treat and diagnose specific medical conditions, whether physical, psychological or emotional. I voluntarily participate in these activities knowing the risks and consequences and agree to assume all consequences, known or not. I release trainer Mrs Elif Köse from all responsibilities, costs and damages that may arise from participating in the above-mentioned activity. I agree to accept financial responsibility for costs related to treatment. By adding my name below, I acknowledge that I have read the above warning and agree to proceed with full responsibility, and understand that I have waived certain rights by signing and signing this release of liability freely and voluntarily without any external influence.

Clear

Please SIGN HERE

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