WELCOME

WELCOME to your first breathwork session with Break Thru Fitness.  I am sooo glad you are here! Please take time to read through the form and answer the questions as accurately as possible before you sign it, so you can receive the best care and understand your rights and responsibilities.

MY MISSION

PROMOTE PHYSICAL AND EMOTIONAL HEALTH (BUILD CONNECTION, DECREASE PAIN, DEPRESSION AND ANXIETY...) THROUGH THE POWER OF BREATH.

PURPOSE AND PROCEDURE

The purpose of breathwork is self-care. It is the number one way to decrease stress by shifting the body from the sympathetic nervous system (fight or flight) to the parasympathetic N.S. (rest, digest, safety, and connection) It is beautiful way to pause in your day and care for your body, mind, and spirit. Benefits occur in 5 slow breaths to hour-long daily practices. It is easy, effective, and accessible to everyone! 

In a one-hour session, I will spend time educating my client on the benefits of breath, and how to breathe effectively. Together we will discuss the intention of the session. I will then lead the client in a guided meditation, begin the breath pattern and then end the session with a guided meditation.  The client will have time to write in a journal or share their experience should they choose to do so.

RISKS

Breathwork is a completely safe practice for those who are not contra-indicated. Those who have cardiovascular issues, eye trouble, or certain psychological diagnoses... will need to receive permission from their dr.  A full list is found in the medical form. 

The body may respond to breathwork in physical ways that may seem odd. Tetany is the most common physical side effect; it’s where your hands will curl inwards toward your heart. This passes soon after releasing the breath pattern. 

It is likely you will experience some strong emotions! This may be uncomfortable to you, however, this is safe and encouraged!! It is possible to be retraumatized through breathwork, though it is extremely rare when practiced correctly.  As a trauma-informed practitioner, I am aware of the signs of a breather moving toward retraumatization and the steps to help them stay grounded in the present.  I also give the breather full agency to stop at any time as the responsibility to not push too far ultimately lies with the breather.  Both breather and facilitator work together to ensure a safe, beautiful journey. 

BENEFITS

It is no secret that most of us struggle with the everyday pressures of life. We’re living in an age where we’re busier than ever, and therefore, disconnected from our bodies. It's pretty normal for us to be constantly stressed, anxious, worried, and overwhelmed. Breathwork allows us to be still, be with ourselves,  and breathe through our experiences. We find peace and calm in the power of our breath, among other things:

*Immediate stress reduction & anxiety relief.

*Connect with your emotions

*Respond to your emotions instead of reacting

*Internal massage to your organs.

*Connect to self, others, and God

*Reduces toxins in your body

*Provides an energetic release.

*Provides energy & mental clarity.

*Deepens your appreciation for your body.

*Release trauma that has been stuck in your system for years.

*Better access your intuition, higher self, and source.

 

GENERAL INFO

EXPERIENCE

 

RELEVANT HISTORY

In the space below, please relate any traumatic experiences or information you would like me to be aware of so that I am able to hold a safe space for you. Details are not required. Sharing the intensity, how much time has passed since the event, and whether or not you have learned coping skills can be helpful information for me to hold a safe space for you and understand better what type of session might best support your body.

Be aware that small fears and uncertainties over time can cause great trauma as well. If you are experiencing this type of trauma, please let me know how raw, exhausted, numb or...... (you fill in the word) you feel so that I can help your body find safety in out sessions.  We will check in before every session, so you will always have an opportunity to share where you are if you wish.

MEDICAL HISTORY

 

If you have answered YES to one or more of the above questions, you MUST CONSULT A PHYSICIAN before engaging in breathwork. Tell your physician which questions you answered ”yes” to. After a medical evaluation, seek advice from your physician on whether or not breathwork is a safe practice for you.

By signing below, you attest to the truthfulness of your statements and answers. We reserve the right to determine eligibility for engagement and participation in our programs based on the answers given. 

WELCOME

WELCOME to your first breathwork session with Break Thru Fitness.  I am sooo glad you are here! Please take time to read through the form and answer the questions as accurately as possible before you sign it, so you can receive the best care and understand your rights and responsibilities.

CONFIDENTIALITY

Your privacy is important to us. All information we obtain from you before, during, and after the session shall be kept confidential and will not be released to anyone without your prior written consent. However, we may use data that does not personally identify you for statistical or testimonial purposes.

PAYMENT

Payment will be made at the time of scheduling. The client is responsible for the cost of session fees plus processing fees. Break Thru Fitness has a No Refunds policy. You will be able to reschedule a canceled session one time within 2 weeks of the original date. Second cancels, no-shows, and cancelations within a 12 hour window of the session will not be able to reschedule.

LIABILITY

As the client, and in consideration for my participation in breathwork sessions with a Break Thru Fitness (BTF) Facilitator, I agree that my participation is entirely voluntary and that I assume any risk associated with participation. Any actions or lack of actions, taken by me, the client, of such advice is done so solely by choice and responsibility, and any harm, injury, or loss that may occur to me or my property as a result of my participation in breathwork, is neither the responsibility nor liability of BTF or trained Facilitator.

My signature below acknowledges that the trained Facilitator is an independent contractor of Pause BreathWork (PBW), and PBW has no control over and assumes no responsibility for the acts or omissions of trained Facilitator.

I understand that during the session I may be photographed or videotaped for promotional purposes. I understand this will only happen with my knowledge and that by staying for the session and signing this form, I give my full consent.  BTF promises to take utmost care of any footage of me and will pledge that this footage will only be used for advertising purposes of BTF and not distributed in any way beyond advertising for BTF and it's subsidiaries - Break Thru Wellness and Exhale, within the boundaries of the law that applies to this agreement. My signature confirms I agree to these terms and is my consent for my image to be used in promoting BTF. 

I understand that breathwork is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment, and I will not use it in place of any form of therapy. I acknowledge the facilitator is not a therapist of any kind and any advice or counsel I feel I have received from the facilitator is followed at my own risk.  I recognize that breathwork requires emotional, physical, and mental effort, exertion, and behavioral experimentation, on my part, which may cause physical, mental or emotional injury. I fully acknowledge and take full responsibility for all the risks involved. I understand that it is my responsibility to consult with my healthcare provider prior to participating in breathwork..

In the event that I am injured physically, emotionally, mentally, spiritually, or in any other way,  I agree to assume any financial obligation, either through my personal health insurance or through some other means, for any medical costs I incur. BTF and Facilitator assume no responsibility for any medical expenses, injury, or damage suffered by me in connection with the use of any facilities or services in connection with the breathwork session.

IN CONSIDERATION OF MY PARTICIPATION IN BREATHWORK, I HEREBY GENERALLY RELEASE, AND PROMISE TO INDEMNIFY, DEFEND, AND HOLD HARMLESS BTF AND Facilitator, AND THEIR RESPECTIVE AGENTS AND EMPLOYEES (THE “RELEASE PARTIES”), FROM ANY LIABILITY WHATSOEVER. I will reimburse BTF and Facilitator for any damages, reasonable settlements and defense costs, including attorney’s fees, that they incur because of any such claims made against them. I agree that the terms of this agreement, including the indemnification obligations in this paragraph, will be binding on my estate, and my personal representative, executor, administrator or guardian will be obligated to respect and enforce them. This RELEASE does not extend to claims for gross negligence, intentional or reckless misconduct, or any other liabilities that applicable law does not permit to be excluded by agreement.

I agree that the purpose of this agreement is that it shall be an enforceable RELEASE OF LIABILITY AND INDEMNITY as broad and inclusive as is permitted by Colorado law. I agree that if any portion or provision of this agreement is found to be invalid or unenforceable, then the remainder will continue in full force and effect. I also agree that any invalid provision will be modified or partially enforced to the maximum extent permitted by law to carry out the purpose of the agreement.

I understand that this is a contract that affects my legal rights, and I have read and understood this form and all its contents, and by signing, I agree to the terms and conditions stated above and voluntarily participate in the program.
 

QUESTIONS

If you have questions or concerns, please reach out via text (970) 214-0741 or via email at btfitnessco@gmail.com.

By filling out and signing this form, I hereby declare that I have read the information above and voluntarily participate in this breathwork program with or without a doctor's consent which is highly recommened by this program.

I understand the potential risks and benefits, as well as my rights and responsibilities. I also have had the opportunity to ask relative questions concerning the program and all of which were explained to me and to my satisfaction.

Thank you for taking the time to fill this out! I look forward to working with you!! Laura