I, certify that I am a competent adult of at least 18 years of age or that if I am a minor under the age of 18, I understand that the consent of my parent/legal guardian/person having legal custody will also be required before treatment.

This Informed Consent is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assignees.

I certify that I am in adequate physical, emotional, and mental health to participate in a Breathwork session (If not, please specify on the opposite side

I acknowledge that should this information change, it is my sole responsibility to notify my Breathwork Facilitator Satya Morillas (The Breath Act) from now on

I, consent to and authorize the facilitator to guide me in a Breathwork Session as specified by my facilitator. This session may include energy healing, vocal toning, tapping, touch work, and integration coaching support.

I understand that the Facilitator is not a licensed physician or doctor and does not dispense medical advice or prescribe the use of any technique as a form of treatment for any physical or psychological conditions without the advice of a physician - either directly or indirectly.

As a Breathwork Facilitator, The Facilitator offers information of a general nature to help clients in their journey toward greater self-awareness, mind-body connection, and emotional, mental, physical, and spiritual well-being and The Facilitator assumes no responsibility for how I (the client) may use this information.

Breathwork is not recommended for people with epilepsy, seizures, cardiovascular problems including angina or heart attacks, high blood pressure, aneurysms, glaucoma, retinal detachment, severe osteoporosis, or recent physical injuries, surgery or illness - particularly involving the brain, mouth, teeth, nose, throat, thyroid, immune system, lymphatic system, lungs, chest, ribs, spine, neck and/or reproductive organs.

Breathwork is not recommended for people with a personal history of mental illness, personality disorders, hospitalization for any psychiatric condition or emotional crisis, suicidality psychosis or pregnancy.
 Possible side effects may include dizziness, fainting, changes in body temperature, disorientation, tingling, cramping, emotional breakthroughs, feeling physical, mental, energetic and/or emotional triggering and/or vulnerability.

The nature of the service/session has been explained to me and/or is available to me in writing and any questions I had regarding the session(s) have been answered to my satisfaction.

I understand that I have the right to refuse to participate in the session. No guarantee, warranty or assurance has been made to me as to the results that may be obtained. I certify the above information is correct to the best of my knowledge.

I agree to adhere to all safety precautions and regulations during my treatments/sessions with The Facilitator.

I will not hold The Facilitator, The Breath Act or any associated companies or members of their staff responsible for any errors or omissions that I may have made in the completion of this form and the sessions.