Breathwork and Somatic Liability Waiver Form
Eden Neves
Somatic therapy uses the body to guide the process of personal transformation. I understand that Somatic therapy and Breathwork includes release of emotions, sound, movement, breathing in a non-regular manner and physical touch by the facilitator.
Name
First Name
Last Name
Birth Date
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Email
example@example.com
Contact Number
-
Area Code
Phone Number
Emergency Contact
Name
First Name
Last Name
Contact Number
-
Area Code
Phone Number
Relationship
Medical History
Breathwork is not recommended and is not safe under certain medical conditions. I will make the facilitator aware of any medications I am currently on, medical conditions or physical limitations before the session.
Contraindications
None
Asthma
Anxiety
Heart Disease
Mental illness (Bi-Polar, Schizophrenia)
High Blood Pressure
Epilepsy
Depression
Cardiovascular Disease
Seizure Disorder
PTSD/Trauma
Recent surgery
Other
Please specifier any health issues that you may have.
Are you taking prescription medication?
Yes
No
If so, which medication and how often do you take?
Are you pregnant? If so, how many weeks.
Do you have any questions or is there anything else you'd like to share?
Your permission will always be asked for before any physical contact occurs. It is my responsibility to refuse touch if it does not feel comfortable, or to ask that touch be terminated if it becomes uncomfortable. If I feel I have an injury present that may put myself or others at risk I will let the facilitator know before participating in any activities. I assume full responsibility for any and all injuries or damages which may incur through participating any activities.
Your signature below indicates that you have read and understand this contraindications form and the information you have provided is truthful. I hereby agree to release and waive any claims that I have now or may have hereafter against my facilitator and support team.
Date
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Year
Date
Signature
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