Appointment Request Form

Apply to Work with Me

Welcome! Below are some questions to see if we are the right fit for each other. All answers are completely confidential, so if you could please answer them as best as you can :) I will get back to you within 24 hours.
Full Name*

First NameLast Name
Email Address*
example@example.com
Instagram:
What services were you after?*
What is your intention for working together?*
What challenges are you facing at the moment?*
Have you experienced a breathwork session before?*
Are you pregnant or on any medications? Please advise *
Contraindications to breathwork: There are some contraindications to activated breathwork. If you any of the following applies to you, this breathwork experience may not be suitable for you.Pregnancy. A personal or family history of epilepsy, seizures, cardiovascular problems including angina or heart attacks, high blood pressure, aneurysms, glaucoma, retinal detachment, osteoporosis, or recent physical injuries, surgery or illness - particularly involving the brain, mouth, teeth, nose, throat, thyroid, immune system, lymphatic system, lungs, chest, ribs, spine, neck and/or reproductive organs. A personal history of mental illness, personality disorders, hospitalization for any psychiatric condition or emotional crisis, suicidality, psychosis or a current drug/alcohol addiction.Do you have any of the above contraindications? *
If your answer is yes, please explain below or the medication you are using, so I can best help you
Anything else you want to share?
Thank you for submitting! Look forward to connecting with you soon, I will send you an email within the next 24 hours
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Apply to Work with Me