• Client Intake & Waiver

  • Welcome to The Focused Breath.

    This form helps us support your breath, body, movement, recovery, and overall wellness safely and effectively.

    Please complete the following intake and waiver prior to participating in services, classes, workshops, coaching, breathwork, yoga, meditation, or related wellness activities offered through The Focused Breath.

  • Client Information

  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Does your work regularly involve any of the following? Check all that apply.

  • Your Movement & Lifestyle

  • How many hours per week do you typically exercise or intentionally move?
  • What types of exercise or movement do you regularly participate in? (Select all that apply.)*
  • Do you currently practice, or have you previously practiced, any of the following?

  • Your Breathing

  • During a typical DAY, how do you usually breathe?*
  • Do you regularly experience any of the following during sleep or upon waking? Select all that apply.*
  • Have you ever been diagnosed with, evaluated for, or told you may have sleep apnea or another sleep-related breathing disorder?
  • Where do you notice your breathing movement most often when you are at rest?
  • Which of the following do you experience regularly? Select all that apply.
  • Have breathing exercises, breath holds, or intentionally changing your breathing patterns ever caused any of the following? Select all that apply.

  • Body, Tension, & Pain

  • Where do you regularly experience tension, discomfort, or pain? Select all that apply.
  • Have you recently experienced any of the following? Select all that apply.*
  • Do you currently experience any of the following? Check all that apply.*

  • Your Current State

  •
  • Approximately how many hours do you typically sleep per night?

  • Health & Safety

  • Have you ever been diagnosed with, or are you currently being evaluated for, any of the following?*
  • Are you currently taking any mediations that may be relevant to you breathing, heart rate, blood pressure, sleep, pain, or exercise tolerance?*
  • Are you currently pregnant or is there a possibility you may be pregnant?*
  • Has a healthcare professional advised you to limit or avoid exercise, breath holding, breathing exercises or any particular movements?*

  • Your Goals

  • What are you hoping to improve, experience, or gain through this work?
  • How much time could you realistically dedicate to a home breathing practice on most days?

  • Care Team

  • Are you currently working with any healthcare, wellness or performance professionals related to the goals you're bringing to me? Select all that apply.

  • Breathwork, Movement & Wellness Informed Consent

  • I understand that services provided through The Focused Breath may include breathwork, breathing exercises, meditation, mindfulness practices, yoga, movement, relaxation techniques, nervous system regulation strategies, and wellness education.

    I understand that participation in these activities may involve physical movement, changes in breathing patterns, breath retention exercises, emotional responses, relaxation responses, and nervous system activation or downregulation.

    I acknowledge that possible experiences may include, but are not limited to:

    • Lightheadedness
    • Dizziness
    • Tingling sensations
    • Emotional release
    • Temporary discomfort
    • Increased awareness of stress or emotions
    • Physical fatigue or soreness

    I understand that participation is voluntary and that I may stop or modify participation at any time.

    I understand that these services are educational and wellness-based in nature and are not intended to diagnose, treat, cure, or replace medical or psychological care.

    I understand that I am responsible for communicating any discomfort, limitations, injuries, or concerns during participation.

  • Assumption of Risk & Liability Waiver

  • I, the undersigned Participant, desire to participate in classes, sessions, workshops, or activities involving breathwork, yoga, meditation, and related wellness practices (collectively, the "Activities") offered by The Focused Breath, LLC, and Blake Boyer ("Released Parties").


    Acknowledgment and Understanding of Risks I understand and acknowledge that the Activities involve physical exertion, stretching, balancing, deep breathing techniques (including pranayama/breathwork), guided meditation, and other practices that may be physically and/or emotionally demanding. These Activities carry inherent risks, including but not limited to:


    ● Muscle strains, sprains, tears, joint injuries, or aggravation of pre-existing conditions
    ● Dizziness, lightheadedness, fainting, hyperventilation, or emotional release
    ● Heart strain, breathing difficulties, or other physical/psychological effects
    ● Injury from falls, improper form, or environmental factors
    ● Aggravation of medical conditions (e.g., high/low blood pressure, pregnancy, asthma, epilepsy, anxiety disorders, heart conditions, back/neck issues, recent surgery, or any other physical/mental health concerns)


    I understand that breathwork and intense meditation can sometimes lead to strong emotional or physical responses, and these practices are not a substitute for medical treatment, therapy, or professional mental health care.

    Assumption of Risk I voluntarily assume all risks associated with participating in the Activities, whether known or unknown, and even if arising from the negligence (but not gross negligence or willful misconduct) of the Released Parties.


    Release and Waiver of Liability In consideration of being permitted to participate in the Activities, I hereby, on behalf of myself, my heirs, executors, administrators, successors, and assigns:
    1. Release, waive, discharge, and covenant not to sue the Released Parties from any and all liability, claims, demands, actions, causes of action, damages, costs, expenses (including attorneys' fees), or losses of any kind arising out of or related to any injury, illness, death, property damage, emotional distress, or other loss I may sustain as a result of participating in the Activities, including those caused by negligence (but excluding gross negligence or intentional acts).
    2. Agree to indemnify and hold harmless the Released Parties from any claims brought by me or on my behalf, or by anyone else arising from my participation.


    Health Representation I represent and warrant that:
    ● I am in good physical and mental health and have no medical conditions that would prevent safe participation.
    ● I have consulted a physician regarding any concerns and have received clearance if needed.
    ● I will immediately inform the instructor of any changes in my health or any discomfort during class.
    ● I will listen to my body, modify or stop any practice if needed, and not push beyond my limits.


    Medical Emergency Consent In the event of injury or medical emergency, I authorize the Released Parties to seek emergency medical treatment on my behalf and agree to be responsible for all related costs.


    Voluntary Participation My participation is voluntary, and I understand this is a full and unconditional release of liability to the maximum extent permitted by law.


    I have read this entire document carefully, understand its terms, and sign it of my own free will without duress.

  • Media Release (Optional)

  • From time to time, photos or videos may be captured during classes, workshops, or events for educational or promotional purposes.

  • Media Consent

  • Signature & Agreement

  • By signing below, I acknowledge that I have read, understood, and voluntarily agree to the terms outlined in this intake and waiver form.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: