Work with me 1:1 Form

Work with me 1 on 1
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Postcode
Phone Number*
Age *
Emergency Contact *
Phone Number*
What modality are you interested in? (You can tick more than one!)

Breathwork JourneysRoot Cause TherapyBreath Retraining and Relaxation FlowsEmotional Integration ProcessesYoga and MeditationEmbodiment and SomaticsOther
What location will you be doing sessions? (You can tick more than one!)

Croydon NthOnline via ZoomOther
Are you currently experiencing any of the following?*

AsthmaMuscular InjuryJoint InjuryPregnancyHigh blood pressureLow blood pressureDizzy/Fainting spellsSeizuresDiabetesSleeping IssuesSurgery in the last 5 yearsPanic attacksAnxietyDepressionDissociationDerealisationPTSDSkin conditionsFlu-like symptomsTrauma related issuesSleep apneaSnoringCurrently smokingSmoked in the pastNone of the aboveOther
Are you experiencing any pain in your*

NeckShouldersUpper backLower backLegsHipsArmsHead or faceNone of the aboveOther
Please tick all that apply to you. This information pertains to Breathwork.

Have a family history of allergiesHave a family history of epilepsyHave a family history of asthmaHave had dental extractionsHave had dental appliances or bracesTonsils removedAdeniods removedRoot canal therapyMercury amalgam fillingsSuffered from TMJ priblemsHave had Jaw/TMJ surgery
CONTRAINDICATIONS We hold participants' safety in high regard. If you have any of the following, it may not be safe for you to participate in certain types of breathwork. Please tick if you have any of the following and I will contact you to discuss further if necessary.*

EpilepsyChronic Heart ConditionsChronic AsthmaFirst Trimester of PregnancySchizophreniaBipolar DisorderRecent Brain InjuryNone of the Above
DISCLAIMER - Please Read Carefully

I, the undersigned, understand that Breathwork, Root Cause Therapy, Emotional Healing Processes, Somatic Work, EFT and Meditation are not a substitute for medical attention, examination, diagnosis or treatment and any changes to prescription medication or medical appliances should be discussed with my prescribing practitioner.

I should consult my GP prior to beginning any program for my overall wellbeing.

I accept that neither the ‘Instructor’, nor the ‘Hosting Facility’ is liable for any injury, or damages, to person or property, resulting from participating in these sessions.

I am aware of the benefits and risks of these sessions and that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments and that there may be additional risks based on my physical condition.

I understand that I will have the opportunity to discuss with the facilitator the nature of the modality and any other procedures.

I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

I understand that I have the right to notify the therapist if the pressure needs to be altered and that I am also able to terminate the session at any time.

I have been given a chance to ask questions about the session and my questions have been answered.

I have read and consent to the above, and by signing below I agree to the above named procedures.

I understand that this is a course of health education which includes breathing exercises and lifestyle guidelines.

I understand that the method taught to me is tailored to suit me and that completion of this does not qualify me to teach any part of this.
PHOTOGRAPHY WAIVER Please be aware that Soultree Moves will be taking photos and/or videos that are considerate of a person in a process. Soultree Moves may use the material produced to further promote the essence of its' work through social media, newsletters and website. To ensure the privacy of individuals, images would not be identified using full names without written approval from the photographed subject. Do you consent to images being recorded?

YesNoLeaning towards yes, but please show me and ask me first
Payment Methods:

To secure your booking, please head to www.trybooking.com/CXWDW

From there, please click on your chosen session type.

Click on Work with me 1:1

Choose your modality. (Discounted 3-packs available)

or

You could choose the EVOLVE - 12 week program - Completely supported and discounted.

If you're new to Soultree Moves 1 on 1 work, please choose Discovery Session and we will map out your plan in that session.

Follow up sessions - Please visit the same payment link.
TERMS AND CONDITIONS

Soultree Moves is a small business sole trader. We spend a lot of time and energy in preparing for your appointments and often paying fees on your space of healing beforehand.

We understand that unanticipated events happen occasionally in everyone's life. In our desire to be effective and fair to all clients, the following policies are honoured.

- Rescheduling - Please give minimum 48hrs notice otherwise $20 extra Booking Fee will be applied.

- Cancellation - Please give minimum 48 hours notice or you will forfeit 50% of your session fee minus $20 non-refundable Booking Fee.

- No Show/Missing an appointment - Without any or proper notification will result in a 50% forfeit of your session fee minus $20 non-refundable Booking Fee.

- If you arrive late, your session may be shortened in order to accomodate following appointments. Depending on how late you are, your therapist will determine the best treatment plan for the time reamining. You will still be responsible for the 'Full' sessions payment.
What days and times are you generally free that would be suitable for a session? You can pick more than one!*

Between the hours of 9-5pm weekdaysAfter work hoursWeekends onlyIt will vary each time
How would you prefer to be contacted?*

TextMessengerPhone callEmail
How did you learn about Soultree Moves?*

FacebookInstagramFriendBrochureOther
Were you referred by someone in the Soultree Moves community? If yes, who? We'd like to thank them.
I agree to all of the above and that i have been open and honest about my health*

Yes
Signature*
Date*

MonthDayYear
Date
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