Group Breathwork

GROUP BREATHWORK

This form only needs to be filled out once - please notify us if your preferences change for future workshops.
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

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Postcode
Phone Number*
Age *
Which Journey will you be participating in?*
Emergency Contact *
Phone Number*
How did you hear about this event?*
Are you currently experiencing any of the below?*

AsthmaMuscular InjuryJoint InjuryPregnancyHigh blood pressureLow blood pressureDizzy/Fainting spellsSeizuresDiabetesSleeping IssuesSurgery in the last 5 yearsPanic attacksAnxietyDepressionPTSDSkin conditionsFlu-like symptomsTrauma related issuesSleep apneaSnoringCurrently smokingSmoked in the pastOther
Are you experiencing any pain in your*

NeckShouldersUpper backLower backLegsHipsArmsHead or faceOther
We hold participants' safety in high regard. If you have any of the following, it may not be safe for you to participate in certain types of breathwork. Please tick if you have any of the following and I will contact you to discuss further.

EpilepsyChronic Heart ConditionsChronic AsthmaFirst trimester of pregnancySchizophreniaBipolar DisorderRecent Brain Injury
Will you be enjoying some of our pure Cacao with us? (If included in the workshop)*
Cancellation and No-Show Policies

We understand that unanticipated events happen occasionally in everyone's life. In our desire to be effective and fair to all clients, the following policies are honoured.

- No refunds. Tickets are transferrable to other participants for the same event or a 50% credit for the next event.

- Please arrive on time or a little before to ensure prompt starting times.

- If you are showing any symptoms, please consider the health of others and stay home.
Disclaimer (Please Read Carefully)

Disclaimer (Please Read Carefully)

I, the undersigned, understand Breathwork is not a substitute for medical attention, examination, diagnosis or treatment and any changes to prescription medication or medical appliances should be discussed with my prescribing practitioner.

I accept that neither the ‘Instructor’, nor the ‘Hosting Facility’ is liable for any injury, or damages, to person or property, resulting from participating in these sessions.

I am aware of the benefits and risks of Breathwork and that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments and that there may be additional risks based on my physical condition.

I understand that I will have the opportunity to discuss with the facilitator the nature of the modality and any other procedures.

I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

I have been given a chance to ask questions about the session and my questions have been answered.

I have read and consent to the above, and by signing below I agree to the above named procedures.
I agree to all of the above and that i have been open and honest about my health*

Yes
Were you referred by someone?
It is possible there will photography of this workshop, do you consent to your photograph being taken and used for promotional purposes of my work and events of similar nature?
Signature*

Clear
Date*

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Date
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