The Monthly Reset
Complete this short form to reserve your place for a guided Soma Breath® journey and sound bath experience.
Your Details
First Name
*
Last Name
*
Email Address
*
example@example.com
Mobile Number
*
Pleae enter a valid phone number.
Format: 000 000 000 00.
Before We Begin
Your comfort, wellbeing and safety are my priority. Please let me know if any of the following apply to you before your session.
Pregnancy or possible pregnancy
Yes
No
Prefer not to say
History of epilepsy or seizures
Yes
No
Prefer not to say
Serious heart condition
Yes
No
Prefer not to say
Recent surgery
Yes
No
Prefer not to say
Wears hearing aids
Yes
No
Prefer not to say
Metal implants or medical devices
Yes
No
Prefer not to say
Sensitivity to sound
Yes
No
Prefer not to say
Is there anything else you'd like me to know?
Consent
I confirm the information I have provided is accurate to the best of my knowledge
*
I confirm the information I have provided is accurate to the best of my knowledge
I understand that breath holds are always optional and I may reduce the intensity or skip them at any time
*
I understand that breath holds are always optional and I may reduce the intensity or skip them at any time
I understand that I am responsible for listening to my body throughout the session
*
I understand that I am responsible for listening to my body throughout the session
I understand that breathwork should always be practised seated or lying down, never in water and never while driving
*
I understand that breathwork should always be practised seated or lying down, never in water and never while driving
I have read and understood the information above and consent to taking part in The Monthly Reset
*
I have read and understood the information above and consent to taking part in The Monthly Reset
Participant Signature
*
Today's Date
*
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Month
-
Day
Year
Date
Reserve My Place
Reserve My Place
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