Clone of The Hedge & Wildflower - Client Registration & Intake

Welcome to The Hedge & Wildflower
Welcome to The Hedge & Wildflower
Thank you for choosing to begin your breathwork journey with The Hedge & Wildflower.

Before your session, please complete the following intake forms carefully and honestly. These forms help create a safe, supportive, and trauma-informed experience tailored to your needs.

Your information will remain confidential and will only be used to prepare for your session and support your care.

The complete intake package should take approximately 10–15 minutes to complete.

Please answer each question as honestly as possible. If you are unsure about any question, simply leave a note or we can discuss it together before your session.

Participant Information
Please provide the following information. This information is confidential and is collected to help create a safe, supportive breathwork experience and to contact you if needed regarding your session.
Full Legal Name

First NameLast Name
Preferred Name (Optional)
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name

First NameLast Name
Relationship to You
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Session Requested

Health Questionnaire (Part II)

Please provide any additional information that will help me create a safe and supportive breathwork experience.
1. Please tell me about any injuries, physical limitations, chronic pain, or mobility concerns that may affect your session.
2. Is there anything you would like me to know so I can better support you during your session?
3. Is there anything else you would like to share before we meet?
I confirm that the information I have provided is true and complete to the best of my knowledge.
Participant Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Participation Agreement

Thank you for taking the time to read this agreement.
This agreement helps create a safe, respectful, and supportive breathwork experience for everyone involved. It outlines our shared commitment to ensuring your session is approached with honesty, mutual respect, and personal responsibility.
By participating, I acknowledge that:

Thank you for taking the time to read this agreement.
This agreement helps create a safe, respectful, and supportive breathwork experience for everyone involved. It outlines our shared commitment to ensuring your session is approached with honesty, mutual respect, and personal responsibility.
By participating, I acknowledge that:

My participation is completely voluntary.

I understand that breathwork is a wellness practice and is not a substitute for medical, psychological, or psychiatric care.

I have completed my Health Questionnaire honestly and to the best of my knowledge.

I will inform my facilitator of any changes to my health before my session begins.

I understand that I may slow my breathing, pause, rest, or stop my participation at any time.

I understand that every breathwork experience is unique and that no specific outcome can be guaranteed.

I agree to communicate openly if I experience discomfort, emotional intensity, or require additional support during my session.

I have had the opportunity to ask questions and understand the information provided before signing this agreement.
I acknowledge that:
Together, we've prepared the path. Now it's time to take the next step.
Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Informed Consent

Thank you for choosing to participate in a breathwork session with The Hedge & Wildflower.
This document explains the nature of breathwork, potential benefits and risks, and your rights as a participant. Please read it carefully and ask any questions before your session.
Your participation is always voluntary. You may slow down, pause, or stop your participation at any time.

What is Breathwork?

Breathwork is a guided wellness practice that uses conscious breathing techniques to support relaxation, self-awareness, nervous system regulation, and personal growth.

Breathwork is not a substitute for medical, psychological, or psychiatric care, nor is it intended to diagnose, treat, or cure any condition.
Potential Benefits

Many participants report experiencing:
• Greater relaxation
• Reduced stress
• Increased self-awareness
• Improved emotional resilience
• Mental clarity
• A stronger connection with themselves

Please read the following pages carefully before deciding whether to participate.
"Healing begins with informed choice."
I confirm that:
Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Consent & Release

Consent

I confirm that:

☐ I have read this Informed Consent document and had the opportunity to ask questions.

☐ I understand the nature and purpose of breathwork and voluntarily choose to participate.

☐ I have completed the Health Questionnaire honestly and to the best of my knowledge.

☐ I understand that The Hedge & Wildflower cannot guarantee specific outcomes.

☐ I understand I may stop or pause the session at any time.

Release

To the fullest extent permitted by Ontario law, I voluntarily assume the ordinary risks associated with participating in breathwork and release The Hedge & Wildflower, its owner, facilitators, employees, contractors, and representatives from claims arising from my voluntary participation, except where liability cannot legally be excluded, including claims arising from negligence where such exclusion is prohibited by law.

Participant Declaration

I certify that the information I have provided is complete and accurate to the best of my knowledge.

I understand this agreement and consent voluntarily to participate in breathwork sessions with The Hedge & Wildflower.
Participant Name

First NameLast Name
Participant Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Welcome to The Hedge & Wildflower