1:1 Breathwork Client Intake Form

All information is confidential. You will be charged a $35 non-refundable deposit upon submitting this form. Once received, I will reach out to you to set up your session. Thank you!

First name

Last name

Phone

Emergency Contact

Emergency Contact Phone Number

Your Intentions

What’s calling you to this work right now?

What are you ready to release, soften, or step into?

How do you desire to feel within yourself?

Your Experience

How do you desire to feel within yourself?

How do you usually meet your emotions—do you welcome them, avoid them, or something in between?

Your body and wellbeing

Are there any physical conditions I should be aware of (heart, blood pressure, respiratory, pregnancy, recent injuries)?

Are you currently taking any medications?

Safety & Support

What helps you feel safe, held, and supported?

Are there any sensitivities, triggers, or boundaries you’d like to share?

Final Reflection

If your breath had a voice, what would she want you to hear right now?

I agree to the HOME WAIVER and Breathwork Waiver

Yes, subscribe me to your newsletter.

Signature

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Date

Year

Month

Day

Deposit (non-refundable)

$35