• Sacred Breathwork with Jemma

    Client Waiver & Contraindications Form

  • Contact Information

  • Date of Birth*
     - -

  • Emergency Contact Information

  • Mental Health History

  • Have you seen a counsellor, psychologist, psychiatrist or other mental health professional before, or tried any other therapies such as Kinesiology, Acupuncture or Reiki?*
  • Breathwork may bring to the surface uncomfortable, challenging emotions, memories or traumas. Do you feel you have the resources within yourself and around you to assist with integration and processing post breathwork session?*

  • Medical History

  • Please check all that apply to you:*
  • Do you take any medication that alters brain chemistry like anti-anxiety, anti-depressant, ADD, OCD medications, etc.*
  • Have you had any prior diagnosis of bipolar disorder, schizophrenia or previous psychiatric condition, or been hospitalized for any psychiatric condition or emotional crisis within the last 10 years?*
  • Have you had any major surgeries in the last 12 months?*
  • Please email me about future events and group journeys:*

  • Waiver:

    I have provided true and accurate information in the above waiver form regarding my mental and physical health.

    I understand that Breathwork is a personal growth experience designed to enhance the quality of life, and is not a substitute for psychotherapy and does not substitute for therapy if needed, and does not prevent, cure or treat any mental disorder or medical disease. I understand that I am responsible for creating and implementing my own physical, mental and emotional wellbeing, decisions, choices, actions, and results. As such, I agree that the Breathwork facilitator(s) is not and will not be liable for any actions or inaction, or for any direct or indirect result of services provided by the Facilitator(s). I understand that this Breathwork activity is not medically supervised and that Jemma Bradshaw is neither a licensed psychotherapist nor licensed medical professional and that breathwork is not a substitute for any medical diagnosis or medical treatment.

    ​I understand that I might find Breathwork physically, emotionally, and/or mentally stressful. I hereby affirm that I am in good health and able to participate in this activity. I do not have any physical or mental conditions which would impair my ability to engage in this activity or which would otherwise endanger my health during this Breathwork activity, or which would cause any risk of harm to myself or other participants.

    ​I understand that is my sole responsibility to participate in activities that are appropriate for the current status of my health and to modify the Breathwork activity to accommodate my own needs or limitations. 

    I agreed to indemnify and hold harmless Jemma Bradshaw, and their respective directors, officers, employees, agents, and beneficiaries from and against any and all claims and expenses, including attorney fees, arising out of my participation in this Breathwork activity.

  • Date*
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  • Should be Empty: