• Breathwork Intake Form

    Medical Questionnaire
  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • General

  • Have you ever done breathwork prior to this?*
  • Are you pregnant (to the best of your knowledge) or trying to become pregnant?*
  • Have you had OR do you presently have any of the following conditions? (Check all that apply)*

  •  

    Breathwork Risks & Contraindications


    I understand that conscious connected breathwork may involve rapid or deep breathing and can result in temporary physical or emotional responses, including dizziness, tingling, muscle tension, changes in body temperature, emotional release, or altered states of awareness.


    Breathwork may not be appropriate for individuals who are pregnant or who have certain cardiovascular conditions, uncontrolled high blood pressure, seizure disorders/epilepsy, severe respiratory conditions, recent surgery or significant injury, glaucoma/retinal conditions, or certain serious medical or psychiatric conditions.


    I understand that breathwork is not a substitute for medical or mental health care. I agree to disclose relevant health conditions and medications and to consult a qualified healthcare professional if I am unsure whether breathwork is appropriate for me. I understand that I may slow, modify, or stop the practice at any time. By proceeding, you confirm that you have obtained any medical clearance you require and accept full responsibility for your decision to participate. 

    By signing, you attest to the truthfulness of your statements and answers. We reserve the right to determine eligibility for engagement and participation in our program based upon the answers given.

  • Breathwork Intake Form

    Release & Liability

  • Windtuition Wellness, Inc.

    SheCode Academy Educational Practicum Acknowledgment, Informed Consent & Release of Liability

  • Participant Acknowledgments

  • I understand that the student facilitator is not an employee, contractor, agent, representative, healthcare provider, or legal representative of SheCode Academy or Windtuition Wellness, Inc. The student facilitator is participating independently as a student completing educational practicum requirements.

     

    I acknowledge and agree that:

    • The facilitator leading this session is a student in training and is completing practicum requirements as part of their educational certification program.

    • This session is being provided for educational and training purposes.

    • The student facilitator is not acting as a licensed physician, psychologist, psychotherapist, counselor, social worker, or healthcare provider.

    • Participation in this session does not create a medical, psychological, therapeutic, coaching, or healthcare provider-client relationship.

    • SheCode Academy provides education and training in somatic breathwork facilitation and does not provide medical, psychological, or healthcare services through this practicum program.

    • Completion of the SheCode Academy program does not grant a healthcare license or authorize the diagnosis, treatment, cure, or prevention of any medical or mental health condition.

    • No specific outcomes, results, healing, emotional release, transformation, or personal benefits are promised or guaranteed.

  • Participant Signature

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