BREATHE BETTER Application
This application is for woman who are ready to commit, take consistent action, and create lasting change. All sessions are in person in Huntington Hills NW Calgary, Alberta
Full Name
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First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Are you female?
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Yes
No
Are you currently pregnant?
Yes
No
Any medical conditions or injuries I should know about?
Why do you want the Breathe Better Sessions, what is going on within your mind and body?
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How would you describe your current nervous system state?
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Calm and balanced
Occasionally stressed or anxious
Frequently tense or overwhelmed
Other
How would you describe your breathing patterns?
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I can take full deep breaths
I mostly breathe into my chest
I feel both chest and shallow breathing
I'm not sure
Is restricted breathing affecting your posture?
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Yes
No
Not sure
Can you commit to 8 sessions over 3 months, with the first four sessions once a week and then every 2 weeks for the following 2 months?
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Yes, I can commit to all sessions
No, I may have conflicts
Describe your current lifestyle (work, family, routine, etc.):
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What are your physical goals?
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How would you rate your level of daily physical activity?
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Sedentary (little or no activity)
Lightly active (light exercise/sports 1-3 days/week)
Moderately active (moderate exercise/sports 3-5 days/week)
Very active (hard exercise/sports 6-7 days/week)
Do you currently practice any of the following?
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Yoga
Breathwork
Meditation
None of the above
Other movement practices
How dedicated are you to following daily homecare routines for lasting change?
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Very dedicated – I will follow all recommendations
Somewhat dedicated – I may miss a few days
Unsure – I have trouble sticking to routines
Can you commit to the financial investment/payment schedule for the full 8-session program?
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Yes, I can commit
I need to discuss payment options before booking
No, not at this time
Is there anything else you would like to share about your readiness or motivation for this program?
Submit
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