New Student Breathwork Intake FormPlease note this is for NEW STUDENTS only. If you have attended my classes before you do not need to fill this out. Name * First Name Last Name Email * Gender * Male Female Are you interested in private or group work? * Private Group If you are applying for a group, note which group you want to attend (DATE + LOCATION) How did you hear about me? * What's bringing you into this work? What are the obstacles or intentions you are wanting to work through? * Are you currently pregnant? * Do you have any or history of: seizure disorders/epilepsy/history of seizures of ANY kind? * Do you have any history of: cardiovascular system issues? (Blood pressure, heart rate, heart disease, stroke etc) * Do you have any or history of anxiety, panic attacks, hypersensitivity or general nervous system regulation issues? * Have you been diagnosed with any mental health disorders (bipolar, schizophrenia. PTSD etc.) * Do you have any or a history of blood sugar issues and/or metabolic disorders alike? (diabetes, hypo/hyperglycemia etc) * Is there anything you would like to share about yourself (physically, mentally, emotionally or spiritually) that could be important before participating in practice? * Thank you so much for taking the time to respond. Your intake form has been received and your spot is confirmed. Should there be any contraindications, I will reach out via email.
