Somatic Breathwork Intake Form v1

Somatic Breathwork Precautions + Liability Form
Name*

First NameLast Name
Phone Number*
E-mail*
example@example.com
Somatic Breathwork Facilitator(s) name:*
Somatic Breathwork precaution for pregnant women*

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
Somatic Breathwork precautions for persons with recent surgeries, diagnosed with Epilepsy or severe brain/eye injuries.*

I HAVE NO RECENT SURGERIES OR HEALTH CONDITIONSYES I'VE HAD RECENT SURGERY AND/OR THE HEALTH CONDITIONS LISTED ABOVE - I will participate using Somatic Breathwork nasal only and I will not hold my breath in Kumbhaka
Any advice given by the facilitator is merely informational and educational in nature and are not intended as a diagnosis or prescription for treatment. Consult with your healthcare provider before starting any new therapy or treatment.*

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.
Liability & Claims*

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.
Please prepare to have the following items with you.

1. Comfortable place to lie down

2. Eye mask

3. Headphones are preferred over speakers

4. Blanket

5. Notebook and pen to capture parts of your experience while they are fresh.
What to Expect?

The session will last about 1 hour. By using your breath and listening to curated music, you will reach deeper levels of consciousness. Prepare to experience a transformational breathwork session that will leave you feeling relaxed, lighter and feeling good. Within 24 hours of completing this form, you will receive a ZOOM link to access the session.
Date signed*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Somatic Breathwork Precautions + Liability Form

What to Expect?