IGNITE | Application for Private Coaching & Breathwork

Ignite is a private 90-day coaching and breathwork experience designed for those who are ready to move beyond insight and create lasting change.

This application helps me understand where you are currently, what you are navigating, and whether IGNITE is the right fit for your next chapter.

Please answer each question honestly. There are no right or wrong answers. The more open and accurate you are, the better I can assess how I can best support you.

I personally review every application and will be in touch once your submission has been received.

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

Do you have or have you ever had any of the following?

Asthma (please bring your inhaler)

High blood pressure or cardiovascular conditions

Recent surgery or injury

Epilepsy or seizures

Diagnosed aneurysm (brain or abdominal)

Detached retina or glaucoma

Psychiatric diagnoses (e.g. bipolar, schizophrenia)

Pregnancy (please specify trimester)

Use of strong or psychiatric medications

Are you currently pregnant or believe you may be pregnant?

Yes

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

Yes

Why are you here?

What is happening in your life right now that has led you to apply for IGNITE? What are you no longer willing to carry, tolerate, or repeat? If nothing changed over the next 12 months, what would concern you most?

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

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?

Capacity for change

Time Capacity Over the next 90 days, can you consistently commit time to your personal growth outside of our sessions?

Yes, absolutely

Mostly, with some flexibility required

I'm unsure

What commitments or responsibilities may impact your ability to fully engage in this process?

Financial Capacity If accepted into IGNITE, are you in a position to invest in your growth?

Yes, I am ready to invest

I would require a payment plan

I am exploring options

Support & Ownership When things become uncomfortable, challenging or emotional, what do you typically do?

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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