HypnoBreathwork® Intake Form
Please fill out this form to help us prepare for your session.
Basic Info
Name
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Format
*
Please Select
Virtual via Zoom
In-person San Diego
Where They're At
What is bringing you to breathwork right now?
*
Have you done breathwork before?
*
Please Select
Yes regularly
A few times
Never
Is there anything specific you want to move through or release?
Health + Safety
Do you have any of the following health conditions?
*
Cardiovascular condition
Epilepsy or seizure history
Severe anxiety or panic disorder
Current pregnancy
History of psychosis
Detached retina
Recent surgery
None of the above
Are you currently under the care of a doctor, therapist, or mental health provider?
*
Please Select
No
Yes - please describe below
If yes, briefly describe your current care
Anything else health-related we should know before the session?
By submitting this form you agree to the terms and conditions outlined at ashlynkwilson.com/terms
Submit
Should be Empty: