Breathwork Intake Form
We kindly ask your cooperation in answering the following questions below as accurately as possible since they will assist your facilitator in assessing your needs pre-appointment. All information given will be kept confidential.
Client Information
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Gender
Please Select
Male
Female
Age
Birth Date
-
Month
-
Day
Year
Date
Relationship
What is you relationship status?
Married
Never Married
Separated
Domestic Partnership
Widowed
Single
Other
How would you rate your relationship well-being?
Not Functioning
1
2
3
4
5
6
7
8
9
No Problems
10
1 is Not Functioning, 10 is No Problems
Employment
What is your employment status?
Employed
Unemployed
Retired
Self-employed
Disabled
Student
Homemaker
Other
Family History
Please indicate if there is a family history of any of the following conditions;
*
Yes
No
If yes, is it for yourself?
Or other Family Member?
Anxiety
Depression
Substance Abuse / Alcohol
Obesity
Schizophrenia
Suicide Attempt
Domestic Violence
Respiratory or Cardiovascular issues
Other Illness/Medical Conditions
If you answered 'yes' to any of the above, please explain in more detail.
History
Have you previously received any type of mental health services?
Yes
No
Are you currently undergoing therapy or psychological counselling?
If Yes please specify
Do you have any health issues or injuries?
Are you currently on any medication?
Yes
No
Please list any medication you are currently taking.
Medication Name
Condition
Usage and Dose
1
2
3
4
5
6
Do you have any allergies? (e.g., medications, environmental factors)
If Yes please specify
Contraindications for Breathwork: Please check to confirm you do NOT have any of the following conditions:
NO
YES
Cardiovascular Problems:
Including but not limited to severe hypertension, history of heart attacks, or stroke.
Respiratory Issues:
Severe asthma, history of significant lung diseases such as COPD or pulmonary embolism.
Acute Physical Injuries:
Including recent surgery, fractures, or wounds.
Seizure Disorders:
Including epilepsy controlled by medication.
Glaucoma:
Due to the potential increase in eye pressure during certain breathing practices.
Pregnancy:
Due to the risk of induced labour or fetal distress.
Severe Mental Health Disorders:
Such as severe psychiatric conditions, which could be exacerbated by intense emotional release associated with breathwork.
High Risk of Aneurysms:
Family history or diagnosed cerebral, thoracic, or abdominal aneurysms.
History of Deep Vein Thrombosis (DVT):
Or other thrombotic disorders which can be dislodged during intense physical activities.
Osteoporosis:
Severe osteoporosis that can lead to fractures during physical activities.
Other
Medical or Physical Concern:
That you have been advised by a health professional to avoid strenuous activities including intense breathing exercises.
I confirm that none of the above contraindications apply to me and if they do I have obtained a full medical clearance from a GP before starting breathwork sessions. I understand that it is my responsibility to maintain my own safety during the session and to inform the facilitator of any health changes.
Agree
General Health Information
How would you rate your physical health condition?
Very Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very Poor, 10 is Excellent
How often do you exercise?
None
1
2
3
4
5
6
7
8
9
Very Often
10
1 is None, 10 is Very Often
How would you describe your general appetite?
Very Poor
1
2
3
4
5
6
7
8
9
Very Hungry
10
1 is Very Poor, 10 is Very Hungry
How would you describe your stress level throughout the day?
Very Relaxed
1
2
3
4
5
6
7
8
9
Very Stressed
10
1 is Very Relaxed, 10 is Very Stressed
How would you rate your general happiness and well-being?
1
2
3
4
5
5 Stars - on top of the world
Symptoms
Please answer all of the statements below that describe your concerns
I often experience;
fear of many things
guilt
panic attacks
avoiding people
having nightmares
anxiety, nervousness
discomfort in social situations
sexual issues
Other
I often have;
suicidal thoughts
memory problems
sleeping disorder
struggled to explain myself to others
obsessive thoughts
violent thoughts
stress and tension
medical concerns
fatigue
work problems
Other
I often feel;
lonely
empty
sad
hopeless about the future
excessive guilt
suspicious
Other
Any other information that may be relevant to your Breathwork sessions?
Breathwork
Have you practised breathwork before? (Yes, No)If yes: What types of breathwork have you experienced and who with? (e.g., Holotropic, Rebirthing, Pranayama)
What do you hope to achieve through breathwork? (e.g., stress reduction, emotional release, spiritual insight)
Emergency Contact details
EMERGENCY CONTACT
First Name
Last Name
Emergency Contact - Phone Number
Please enter a valid phone number.
Relationship to Emergency Contact
Final Confirmation
Do you have any questions or concerns you would like to address before participating?
Consent to Participate: I understand that breathwork involves physical and mental exercises that may cause emotional and physical responses. I confirm that I am voluntarily participating in these activities and assume all risks associated with them. I agree to inform the facilitator of any discomfort, emotional or physical, that I experience during the session to adjust the practice accordingly. I confirm that I have provided complete and accurate health information to the best of my knowledge.
I Agree
Signature
Date
-
Day
-
Month
Year
Date
Submit
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