PRE-BREATHWORK WAIVER

PRE-BREATHWORK WAIVER

As a breathwork facilitator, Georgia Liley offers information of a general nature to help clients in their journey towards greater self awareness, mind-body connection, emotional, mental, physical and spiritual wellbeing and Georgia Liley assumes no responsibility for how I (the client) may use this information. Breathwork is not recommended for people with a personal or family history of epilepsy, seizures, cardiovascular problems including angina or heart attacks, high blood pressure, aneurysms, glaucoma, retinal detachment, osteoporosis, or recent physical injuries, surgery or illness - particularly involving the brain, mouth, teeth, nose, throat, thyroid, immune system, lymphatic system, lungs, chest, ribs, spine, neck and/or reproductive organs. Breathwork is not recommended for people with a personal history of mental illness, personality disorders, hospitalisation for any psychiatric condition or emotional crisis, suicidality, psychosis, drug or alcohol addiction. Possible side effects may include dizziness, fainting, changes in body temperature, disorientation, tingling, carpopedal spasms, cramping, emotional breakthroughs, feeling physical, mental, energetic and/or emotional triggering and/or vulnerability. If any of the above apply to you at this time, please consult your doctor or primary healthcare provider before completing this form.
Name*

First NameLast Name
Email*
example@example.com
Date*

MonthDayYear
Date
Father

AliveDeceased
Describe your relationship
Mother

AliveDeceased
Describe your relationship
Caregiver

AliveDeceasedN/A
Describe your relationship
Sibling(s)

AliveDeceased
Describe your relationship
Do you have an intention/goal/something specific you would like to address over the next 3 months?
Have you done breathwork before? Have you tried any other modalities?
What was it like for you growing up? (Physical, mental, emotional, spiritual)
What did you struggle with? (Physical, mental, emotional, spiritual)
What are you still holding on to? (Physical, mental, emotional, spiritual)
How do you feel about yourself/your life? (Physical, mental, emotional, spiritual)
What health issues/diseases/illnesses/surgeries have you had in the past or are experiencing now?
On a scale of 1-10, how aligned do you feel PHYSICALLY in your life right now? (1 = very out of alignment with who I want to be, 10 = totally in alignment with who i want to be)
On a scale of 1-10, how aligned do you feel MENTALLY in your life right now? (1 = very out of alignment with who I want to be, 10 = totally in alignment with who i want to be)
On a scale of 1-10, how aligned do you feel EMOTIONALLY in your life right now? (1 = very out of alignment with who I want to be, 10 = totally in alignment with who i want to be)
On a scale of 1-10, how aligned do you feel SPIRITUALLY in your life right now? (1 = very out of alignment with who I want to be, 10 = totally in alignment with who i want to be)
What are you currently navigating? (physical, mental, emotional, spiritual)
Do you currently have any healing and/or goals you're working towards? (Physical, mental, emotional, spiritual)
How will you know once you have achieved them/got there? (eg, how does it need to be or how do you need to feel in order for you to feel you got value?)
How would you describe your spiritual or religious beliefs?
And anything else you want to share?
Medical History
Do you currently have any diagnosed conditions, illnesses or addictions?*
Are you pregnant?*
List any medications you are currently taking:*
List allergies to medications or substances: (Please if you are allergic to animals, essential oils, perfume etc for your comfort during the breathwork)*
Do you give permission to the breathwork facilitator to apply physical touch including tapping, energy work and light or firm pressure during the session? (Applicable for in person sessions)*
Have you had any recent surgeries or injuries which require physical touch to be specifically avoided or approached carefully? Please specify:*
Emergency Contact Details
Name*

First NameLast Name
Relationship*
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency situations outside of business hours: in the case of an emergency, I should call 111, and should go immeditately to the closest emergency room.

Georgia Liley (Breathe With Geo) does not process insurance claims.

A 24 hour notice of cancellation of appointments is required. Full payment of 1:1 breathwork is due at least 24 hours prior to the appointment. If payment is missed or session is cancelled late, payment will be due in full.

By signing this waiver, I understand that Breathe With Geo does not do any refund policies. I understand all sales are final, and there will be no refund.
I First Name* Last Name* certify that I am a competent adult of at least 18 years of age or that if I am a minor under the age of 18, I understand that the consent of my parent/legal guardian will also be required before treatment.
This Informed Consent is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assignees.

I certify that I am in adequate physical, emotinal and mental health to participate in a breathwork session (if not, please specifiy on the opposite side).

I acknowledge that should this information change, it is my sole responsibility to notify my breathwork facilitator; Georgia Liley (Breathe With Geo).
I First Name* Last Name* consent to and authorize Georgia Liley to guide me in a breathwork session as specified by my facilitator. This session may include energy healing, vocal toning, tapping, touch work and integration coaching support.
I understand that Georgia Liley is not a licensed physician or functional breathing specialist and does not dispense medical advice or prescribe the use of any technique as a form of treatment for any physical or psychological conditions without the advice of a physician - either directly or indirectly.

As a breathwork facilitator, Georgia Liley offers information of a general nature to help clients in their journey toward greater self awareness, mind-body connection, emotional, mental, physical and spiritual wellbeing and Georgia Liley assumes no responsibility for how I (the client) may use this information.

The nature of the service/session has been explained to me and/or is available to me in writing and any questions I had regarding the session(s) have been answered to my satisfaction. I understand that the session may involve risks of complications or injury from both known and unknown causes, and I freely assume these risks.

I understand that I have the right to refuse to participate in the session(s). No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. I certify the above information is correct to the best of my knowledge.

I agree to adhere to all safety precautions and regulations during my treatment/sessions with Georgia Liley. I will not hold Georgia Liley or any associated companies or members of their staff responsible for any errors or omissions that I may have made in the completion of this form.

By signing this form, I agree that the services from Breathe With Geo in all forms have no refund policy. All sales are final.
Client Name*

First NameLast Name
Signature*

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Date*

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Date
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PRE-BREATHWORK WAIVER

Medical History

Emergency Contact Details