Breath Factor Practitioner Training Application

Breath Factor Practitioner Training Application

Share your background, intentions, and readiness so we can confirm the training is a strong fit for everyone involved.
Basic Information
Full Name

First NameMiddle NameLast Name
Preferred Name
Pronouns
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
City / State / Country

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Preferred Contact Method
Professional Background
Current profession or primary area of work
Brief professional background and populations served
Relevant licenses, certifications, education, and training
Current work in helping, healing, coaching, wellness, education, medical, mental-health, spiritual, or body-based profession
Professional liability insurance
Previous breathwork training
Experience with facilitated breathwork, somatic, meditation, nervous-system, or embodiment practices
Intention and Alignment
Why are you feeling called to this training at this time?
How do you hope to apply this training in your work, service, or personal path?
What does trauma-informed facilitation mean to you?
What qualities do you believe are essential in a safe and effective breathwork practitioner?
What personal strengths or experiences would you bring to the training and your future practice?
What areas of growth, challenge, or learning edges are you currently aware of?
Why do you feel Breath Factor is the right training for you?
Personal Readiness and Capacity
Note: This training can be physically, emotionally, and energetically activating. The questions below are intended to assess support needs and readiness, not to diagnose or label you.
Current emotional and nervous-system capacity

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2

3

4

5

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7

8

9

10

1 is Low, 10 is Very strong
Are you currently navigating a major crisis, acute loss, destabilizing transition, or another circumstance that could affect your participation?
Are you currently receiving support from a therapist, counselor, coach, medical professional, or other practitioner?
What practices or resources do you use to regulate, ground, and integrate intense experiences?
Do any physical health, mental health, medication, pregnancy, seizure history, cardiovascular or respiratory health, recent surgery, or other considerations affect your safe participation?
Please share any relevant details or accommodations that would help us support your participation safely.
Have you experienced significant dissociation, psychosis, mania, or psychiatric hospitalization within the past two years?
Are you currently using substances in a way that may interfere with attendance, participation, judgment, or integration?
What support would help you participate safely and successfully?
Training Commitment
Can you attend all three full training days (August 28–30, 2026)?
Are you willing to complete all required pre-work and preparation?
Are you willing to participate in partner and small-group practice as both facilitator and participant while honoring boundaries?
Are you willing to receive direct, respectful feedback and engage in self-reflection?
Are you willing to practice within your training, licensure, and professional scope and refer out when appropriate?
If accepted, are you prepared to make the tuition commitment of $2,200?
Please share anything that might prevent you from fully participating in or completing the training.
Ethics and Professional Responsibility
I understand this training does not qualify me to diagnose, treat, or represent myself as a licensed healthcare or mental-health provider unless I separately hold the appropriate license
I agree to respect participant confidentiality
I agree to honor consent, autonomy, and personal boundaries
I understand that certification or completion depends on attendance, participation, demonstrated competency, and adherence to ethical standards
I understand that acceptance may require a follow-up conversation
Final Reflection
What do you most want our team to know about you?
What questions do you have about the training?
How did you hear about Breath Factor Practitioner Training?
Website, social media, or professional profile link
Applicant signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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Breath Factor Practitioner Training Application

Basic Information

Professional Background

Intention and Alignment

Personal Readiness and Capacity

Training Commitment

Ethics and Professional Responsibility

Final Reflection