Somatic Breath Journey - Client Consultation

SOMATIC BREATH

Client Waiver Form
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Mobile Phone

Phone Number
Preferred Method of Contact
Emergency Contact Information
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Medical History
Please check all the apply

Other
Do you smoke cigarettes?
Caffeine use?
Are you currently taking prescription medication?
If so, which medication and how often do you take?
Have you had any surgeries in the last 12 months?
If yes, please specify:
Are you pregnant? How many weeks?
Why are you wanting to experience this work?
What would you like to get out of your journey?
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
Reason for seeking help
Average hours of sleep per night
Have you tried any other therapies such as hypnotherapy, reiki, kinesiology?
Additional comments or concerns
*Your signature below indicates that you have read the contraindications form and the information you have provided above is truthful.
Date
Signature
Should be Empty:

SOMATIC BREATH