Appointment Request Form

Compassionate Co Client intake form
Full Name

First NameLast Name
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Age
What would you like to work on?
Have you ever practiced breathwork before? If yes, please specify which type below.
Do you have any of the following health conditions?

Heart conditions or arrhythmiaHigh or low blood pressureUntreated PTSDRecent panic attacksEpilepsyPCOSBipolar disorder, psychosis or schizophreniaDetached retina or glaucomaHistory of strokes of seizuresRecent major surgeryAsthmaAnxiety/overwhelmDepressionSleep disordersSinus congestion/flu/cold virusOther, please specify below
If you have answered yes to any of the above, please provide some detail below.
Is there a possibility you may be pregnant?
Please state a day that would suit you best for a free consult call.
I understand that I have provided the answers to the questions above with the knowledge I possess at the time of answering. I acknowledge that the breathwork facilitator does not diagnose illness, disease or any other physical or mental disorder. The facilitator does not prescribe medical treatment. I will inform the facilitator of any changes in my current condition at the time of each session. I declare that I am fit and healthy enough to participate in breathwork practices, and I submit to practices under my own volition.
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Compassionate Co Client intake form