Shonielay Client Consent Form

Vanta Breathwork Disclaimer
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Contact Information — Email*
Contact Information — Phone*

Area CodePhone Number
Health Screening Questionnaire
1. Do you have any current medical conditions? (Please specify)
2. Are you currently taking any medication? (Please specify)
3. Do you have a history of mental health issues? (Please specify)
4. Are you pregnant or planning to become pregnant?

YesNo
5. Do you have a history of cardiovascular disease or respiratory issues?

YesNo
6. Have you undergone any surgeries in the past year?

YesNo
7. Do you have any allergies or sensitivities? (Please specify)
List of Unsuitable Persons for Treatment

 Individuals with severe cardiovascular conditions  Individuals with epilepsy or history of seizures  Pregnant individuals  Individuals under the influence of drugs or alcohol  Individuals with severe mental health conditions without medical clearance
Explanation of the Treatment

Vanta Breathwork is a form of complementary therapy that involves guided breathingexercises aimed at promoting physical, emotional, and spiritual well-being. Thetreatment hopes to achieve a state of deep relaxation, emotional release, andheightened awareness. Participants may experience a range of sensations includingbut not limited to: Sensual, orgasmic/Shakti energies Ecstatic, Kundalini awakenings Vibrating, trembling, shaking, and spontaneous physical movement Tetany (including sometimes the jaw)
Side Effects

Participants might experience the following side effects, ranging from minor tosevere: Mild discomfort or dizziness Emotional release or catharsis Physical sensations such as tingling or numbness Intense emotional or spiritual experiences
Touch in Therapy

N/A
Declaration
Permission to Touch: I give my permission to be touched on the shoulders, back, and lower abdomen.*

YesNo
Consent & Acknowledgement*

I acknowledge the possible risks and side effects.I am satisfied with the explanation of the treatment and I wish to go ahead.
Client Signature*
Date of Signature*

MonthDayYear
Aftercare Advice
Consent Form Review
BELIEF CODING® — MASTER FACILITATOR COURSE DISCLAIMER
Acknowledgement*

I have read the above.I agree and acknowledge that I am responsible for my own health and mental well-being and the course creator is not liable for my health, emotional state or mental well-being.
Name*

First NameLast Name
Signed*
Date*

MonthDayYear
Should be Empty:

Vanta Breathwork Disclaimer

Health Screening Questionnaire

List of Unsuitable Persons for Treatment

Explanation of the Treatment

Side Effects

Touch in Therapy

Declaration

Aftercare Advice

Consent Form Review

BELIEF CODING® — MASTER FACILITATOR COURSE DISCLAIMER