Somatic Breathwork Intake Form

Somatic Breathwork Precautions + Liability Form
Full Name*

First NameLast Name
I AM NOT PREGNANTYES I AM PREGNANT - I will only breath through the nose using Perfect Breath and I will not hold my breath in Kumbhaka
I HAVE NO RECENT SURGERIES OR HEALTH CONDITIONSYES I'VE HAD SURGERY AND HEALTH CONDITIONS - I will participate using Somatic Breathwork nasal only and I will not hold my breath in Kumbhaka
I HAVE NO SEVERE MENTAL DISORDERSI HAVE A HISTORY OF SEVERE MENTAL DISORDERS - I will participate using Somatic Breathwork nasal onlyI HAVE A HISTORY OF SEVERE MENTAL DISORDERS - I prefer to participate using Somatic Breathwork mouth breathing with extra precaution from my facilitator
I acknowledge that the facilitator(s) is not a physician, physiotherapist, registered dietitian, registered massage therapist, or psychotherapist. He will not be held liable for failure to diagnose or treat an illness, nor will he be liable for failure to prevent future illness.
It is my responsibility to notify my facilitator if I am feeling unsettled or ungrounded after a session.
YES - I grant permission for light touch to support my journeyNO touching
I waive any right to initiate any claims or litigation against the facilitator(s) for his advice, medicine recommendations, assessments, and all outcomes of his services.
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Somatic Breathwork Precautions + Liability Form