Zazen x BREATHE INTO BALANCE INTAKE AND LIABILITY WAIVER OF CONSENT

BREATHE INTO BALANCE

INTAKE AND LIABILITY WAIVER OF CONSENT FOR SACRED BREATHWORK AT ZAZEN MEDITATION STUDIO
SACRED BREATHWORK JOURNEY INTRO
WHAT IS BREATHWORK?

Breathwork is an umbrella term for the art of consciously controlling our breath. There are many different styles and techniques that fall under this including Pranayama, Functional and Concious Connected Breathwork.

Conscious Connected Breathwork is a transformational and immersive experience, where we breathe in a connected circular pattern without pause. This is accompanied by a deep experiential journey into self. Oxygen levels are intentionally increased and carbon dioxide levels are depleted. This increase in oxygen allows us to enter expanded (or non-ordinary) states of consciousness, breaking out of the "monkey mind" and shifting into higher brainwave states, regulating the nervous system while accessing the subconscious mind and emotional body.

Sacred Breath Journeys are an intuitive, free-form, uninhibited and trauma, somatic and polyvagal informed approach to breathwork. We incorporate intentional and ceremonial containers, healing instruments, soul-invoking playlists, smudging tools and essential oils. In addition to longer and nourishing journeys, post-breath integration, deeply restful savasana and space for sharing and processing your experience at the end. Sacred Breath Journeys activate the parasympathetic nervous system (rest, restore, recalibrate system) through a nose inhale that evokes body safety, nervous system unwinding and full system recalibration and relaxation. I strongly believe nervous system regulation is the missing key to healing and an unlock to our stress and burnout cycles. It is an essential place to start before any deeper subconscious, emotional or inner work can be explored!

Breathwork is multidimensional and works on all four layers of the body - physical, emotional, mental and energetic/spiritual levels.

WHAT IS SACRED BREATHWORK?

Breathwork is deeply transformative, empowering and life-changing work for those willing and ready to venture into their innermost being. Sacred Breathwork is a journey of self intimacy, self-awareness, self-love and compassion, and exploration of the full spectrum of ones emotional body, subconscious mind and beyond.

Breath is a gateway to connecting with our highest self, our most authentic soul expression and returning to the truth of who we truly are before the world conditioned and taught us who we should be. Through the alchemy of breath, we may reclaim and embody all that we are (and always were) and reawaken lost parts of ourselves, returning them back into wholeness. Breathwork empowers one to reclaim their power, intuition, sovereignty, creativity, divine purpose, unique voice and gifts. Through this work, we realize the healer and wisdom lies within; all the answers we seek are already and always were within us.
DISCLAIMER OF LIABILITY

PLEASE READ CAREFULLY
Spiritual and emotional work, breathwork, yoga, meditation and any other form of alternative healing should not be construed as a substitute for direct medical advice from your doctor or other qualified clinician, medical or psychiatric examination, diagnosis or treatment. Anyone interested in breathwork is also responsible for seeking the specific medical or psychiatric attention they need, should they need it.

The information and content available is intended for informational purposes only. It is not intended to diagnose, mitigate, treat or cure any disease or condition. Individuals should consult a qualified health care provider for medical advice.
BREATHWORK JOURNEY IMMERSION CANDIDACY

HOW TO DETERMINE IF YOU ARE A CANDIDATE
Conscious, Connected Breathwork results in certain specific physiological changes in the body and also can result in intense physical and emotional release. Please be aware that these sessions are safe, illuminating, transformative and deeply healing, and can sometimes cause the following:
- Tingling
- Buzzing
- Vibrating
- Trembling, shaking or other physical sensations, including spontaneous physical movement
- Tetany (tightness in the hands or sometimes the jaw- we will guide you on how to work with it and manually release it during the live session)
- Somatic (body) unwinding
- Deep emotional experiencing, release and catharsis
- Trauma release
- Experiencing life force energy (prana) moving through your body
- Unlocking repressed sensual/orgasmic/shakti energies
- Ecstatic, kundalini awakenings (usually for more advanced journeyers)
CONTRAINDICATIONS

To uphold a safe and supportive container it is important to consider medical conditions or symptoms that may not be suitable for Conscious Connected Breathwork:

If you have one of the following medical conditions/symptoms, the Sacred Breathwork method is *NOT* suitable at this time - please do not proceed with registration. I am always open to discussing in more depth.
- Taking any medication that alters brain chemistry like anti-anxiety, anti-depressant, ADD, OCD medications, etc. (if you are off this medication for 90 days the modified breath to start can be discussed)
- Detached Retina
- Glaucoma
- Kidney disease
- Diagnosis of aneurysm of any kind
- Uncontrolled thyroid conditions
- Diabetes (any type)
- Severe Asthma— for mild to moderate asthma, we can discuss but you must bring your inhaler to the session
- Epilepsy
- History of Seizures
- Prior diagnosis of bipolar disorder, schizophrenia or previous psychiatric condition
- Severe psychosomatic disorders
- Recent surgery, stitches or injury (no breathwork until healed)
- Any other medical, psychiatric or physical conditions which would impair or affect ability to engage in any activities that involve deep physical and/or emotional release
If you have one the following medical conditions/symptoms, Sacred Breathwork is available for you in with an alternative modified gentler breath.
- Severe PTSD or trauma (with consultation from healthcare provider)
- High Blood Pressure
- Actively using recreational drugs (must be off all drugs for 72h)
- Pregnancy (modified breathwork is avail for 2nd & 3rd term)
- Cardiovascular disease, including angina, previous heart attack or stroke
- Mid to moderate asthma, we can discuss but you must bring your inhaler to the session
- Hospitalization for any psychiatric condition or emotional crisis within the last 10 years (modified breath is available if healthcare/medical provider is consulted)
**Please email us if you would like to further discuss the contraindications in more detail and if a gentler modifed alternative is possible for participation: hello@breatheintobalance.co**
Client Information

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Name

First NameLast Name
Email Address
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Contact Number
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Emergency Contact Name

First NameLast Name
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Have you experienced Conscious Connected Breathwork before?*

YesNoOther
Have you experienced or do you have a background in*

YogaMediationSomatic Based TherapiesHealing ArtsOther
Do you have any contraindications listed above and/or psychological and medical conditions we should be aware of?*
Are you willing to fully meet yourself even if it requires pushing to your growth edges for greater healing and transformation?*

YesNo
I realize conscious connected breathwork is a powerful and potent tool to access my deeper layers and can greatly intensify my transformational process*

YesNo
BREATHWORK WAIVER OF LIABILITY AND INFORMED CONSENT

NOTE: This is an important legal document. Please read carefully, confirm your agreement for each paragraph and sign at the bottom only if you agree:
Please confirm you have read and agree to the Breathe into Balance Breathwork Intro and Disclaimer of Liability *Initial if you agree below*
Your Initial here
Please Initial you have read and understood the Breathe Into Balance Sacred Breathwork contraindications list above and have advised of any medical conditions before the session? *Initial if you agree below*
Your Initial here
I understand that Breathwork is a powerful experiential tool for accessing my deeper layers and that it can greatly intensify my transformational process. Through the practice of deep breathing, guidance and music I will embark on a journey into myself. Because breathwork can potentially bring up intense emotions and strong physical experiencing, I have been informed that Breathwork is not recommended for individuals with severe PTSD or unprocessed trauma, pregnancy (at any stage), certain types of cardiovascular disease or history of heart attack, epilepsy, aneurysm, history of seizures, diabetes, severe asthma, mental health imbalances, psychosomatic ailments, certain chronic conditions, recent surgery, infectious diseases, certain medications, or other physical limitations.*

AGREEDO NOT AGREE
I hereby acknowledge that I have no such problems or conditions as listed above, or any other physical, mental or emotional conditions that would prevent me from participating in Conscious Connected Breathwork. I have fully disclosed my physical, mental and emotional background to the facilitators involved prior to my participation. I realize that all staff, assistants, volunteers and/or support team are here only as a guide to my process and that none of the staff, assistants, volunteers and/or support team are here to replace any form of traditional mental or health treatments. I have spoken with any and all mental and physical health care professionals that I believe would be necessary to ask whether I would be an appropriate candidate to participate in the breathwork process, based on my physical, emotional and mental health history and current condition(s) (if I felt this was necessary). I hereby attest that there is no reason why I should not be able to participate.*

AGREEDO NOT AGREE
To this purpose, I, the participant voluntarily agree to participate in Breathwork and any followup Integration and coaching sessions and I agree to indemnify and hold harmless Jessica Pavlin and Breathe Into Balance against any and all claims and expenses, including attorneys fees, arising out of my participation in Breathwork, integration or coaching sessions. In consideration of my participation in the Breathwork, integration or coaching sesions, I hereby waive and release Jessica Pavlin and Breathe Into Balance from any and all claims, costs, liability, and expense for any injury, loss or damage whether known, anticipated or unanticipated arising from my participation in Breathwork, integration or coaching sessions *Initial if you agree below*
Your Initial here
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ADDITIONAL QUESTIONS

This additional information is optional and will support us working together
What brought you to breathwork and do you have any specific intentions as you embark on working with this deeply transformative practice?
Noticing your breath throughout the day...How is your resting breath? Is it full, deep, and diaphragmatic, or quick, shallow and predominantly in the chest? Do you breathe through the nose or the mouth throughout the day?
Do you have any regular practices that support and nourish you? e.g. self-care, self-reflection, exercise or movement, meditation, mindfulness, breathwork, spiritual practice, time in nature etc.
How are you sleeping? (How many hours, quality etc)
How would you rate your current level of stress out a 10 (1 being low and 10 being high)?
How would you rate your general happiness and emotional wellbeing?
Is there anything else you would like to share?
Note: You will automatically be added to the Breathe Into Balance monthly newsletters for more information on upcoming events which you can unsubscribe to at any time.
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BREATHE INTO BALANCE

SACRED BREATHWORK JOURNEY INTRO

DISCLAIMER OF LIABILITY

BREATHWORK JOURNEY IMMERSION CANDIDACY

Client Information

BREATHWORK WAIVER OF LIABILITY AND INFORMED CONSENT

ADDITIONAL QUESTIONS