Clone of Pre-Breathwork Questionnaire & Waiver

Pre-Breathwork Liability Release & Waiver
Name

First NameLast Name
Email
example@example.com
Birthdate

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Pronouns
Medical History

Breathwork is a powerful practice that can affect the body and mind in different ways. It is not recommended for individuals with certain medical conditions. Please review the list below and let the facilitator know if any apply to you.
Breathwork may not be suitable if you have or have experienced:

Personal or family history of epilepsy or seizure disorderCardiovascular conditions (including high blood pressure, angina or heart attacks)AneurysmsGlaucoma or retinal detachmentOsteoporosisRecent physical injuries, surgery or illnessMental health conditions (history of mental illness, personality disorders, psychiatric hospitalization, psychosis, suicidality, or substance/alcohol addiction)PregnancyNone of the above apply to meOne or more apply (please specify below)
Consent to Physical Touch
Do you give permission to the Breathwork facilitator to apply physical touch including tapping, energy work and light or firm pressure during the session?

YesNo
Have you had any recent surgeries or injuries which require physical touch to be specifically avoided or approached carefully?

NoYes (please specify below)
Photo & Video Consent

I understand that photos or video may be taken during this event for promotional or educational purposes. I acknowledge that my participation is voluntary and I may choose whether or not to be included.
Yes, I consent to being photographed/recorded and allow my image to be used for promotional purposesNo, I do not consent to being photographed/recorded
Experience with Breathwork

To help the facilitator understand the group’s background, please indicate your level of experience:
This is my first breathwork journeyI have experienced one or a few breathwork journeys beforeI have a regular breathwork practice or journey experience
(Optional) If you've experienced a specific style of breathwork journey, please share:
Emergency Contact Details
Contact Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Emergency Situations Outside of business hours: in the case of an emergency, I should call 911 or whatever emergency service is available in the location, and should go immediately to the closest emergency room.

Sara Inge does not process insurance claims.
Liability Release & Waiver
I, 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/person having legal custody 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, emotional and mental health to participate in a Breathwork session (If not, please specify on the opposite side).

I acknowledge that should this information change, it is my sole responsibility to notify my Breathwork Facilitator (Sara Inge).
I understand that Sara Inge 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, Sara Inge 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 Sara Inge 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, hospitalization 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.

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. 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 treatments/sessions with Sara Inge. I will not hold Sara Inge 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.
I,name,consent to and authorize Sara Inge 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.
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Pre-Breathwork Liability Release & Waiver

Medical History

Consent to Physical Touch

Photo & Video Consent

Experience with Breathwork

Emergency Contact Details

Liability Release & Waiver