Breathwork & Energy Healing Client Intake Form

Name*

First NameLast Name

Birth Date*

MonthDayYear

Gender*

MaleFemaleNon-Binary

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

What is your preferred method of contact?*

Phone CallEmailText MessageOther

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Name & Relationship*

full name & relationship

Emergency Contact Phone Number*

phone number including area code

Have you ever practiced breathwork before?*

No, this is my first timeYes, but I am a beginnerYes, I have occasionallyYes, I have an advanced experience

Have you ever received any type of energy healing before? (e.g., Reiki, Quantum Healing, Chakra Balancing)?*

No, this is my first timeYes, but I am new to this type of practiceYes, I have received sessions beforeYes, I have advanced experience receiving this kind of healingI am an experienced practitioner

What types of energy healing have you tried before?*

What are your goals for receiving during your session? (check all that apply)*

If you selected "other" above, please describe.

What emotions or challenges are you currently experiencing that you would like support with?*

Do you have any history of trauma, PTSD, or emotional distress that may arise during breathwork or energy healing?*

YesNoUnsure

Please specify if you feel comfortable.

How comfortable are you with deep breathing techniques?*

Not comfortable at allSomewhat comfortableVery comfortable

How would you describe your current energy levels?*

Low – I feel drained and fatigued most of the timeModerate – I have ups and downsHigh – I generally feel energized

Do you have any specific spiritual or energetic practices you currently engage in? (e.g., meditation, yoga, journaling, rituals, etc.). If so, please specify.*

Are you currently taking any medications that may affect your breathwork or energy healing experience?*

YesNo

If you selected "yes" please list those medications and the purpose of medication.

Do you have any existing medical conditions or diagnoses I should be aware of? (e.g., asthma, heart conditions, chronic pain, autoimmune disorders, etc.)*

YesNo

If you checked "yes" to the above question, please provide details. If you selected "no" then type N/A in the text box.*

Are you currently pregnant?*

YesNoI don't knowI'm male

Are there any injuries, surgeries, or recent health issues or conditions that you feel the need to share? If none, then type "none".*

Is there anything else you’d like me to know before our session?

My sessions include a combination of somatic breathwork conducted along with frequency music, the use of crystals, energy healing, and a proprietary healing method known as Quantum Scaling. My healing technique uses universal life force energy while tapping into the quantum field to balance the subtle energies within our bodies to heal and contributes for balanced physical, mental, emotional, and spiritual being. Reiki is not a replacement for traditional medical treatment.

During a session, your healing practitioner will lay their hands on your body in a series of hand positions to deliver energy. You might feel a floating sensation, emotional release, increased relaxation, enhanced sense of balance, centeredness, and calm.

The effects of the combination of these modalities are cumulative in which regular healing sessions can invite significant improvement. Regular sessions support well-being in every way.

If you experience any pain or discomfort during this session, immediately inform the practitioner.

By signing below, I acknowledge that I am voluntarily participating in a somatic breathwork and energy healing session. I understand that this session is not a substitute for medical or psychological treatment and that I should consult a licensed healthcare provider for any medical concerns. I release the practitioner from any liability resulting from my participation.

Please sign below if you acknowledge the given information and give your consent to recieve the treatment.*

Breathwork & Energy Healing Client Intake Form

Health & Wellness Background

Consent & Agreement