Breathwork Appointment Request

Breathwork Appointment Request

Please complete the below request form & I will call you with an appointment time. Please note in person sessions are only held on Fridays.
Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Date of Birth*
Do you suffer from any mental, emotional or physical conditions? Please explain*
Have your tried any other alternative therapies before? Please explain*
Have you had any recent surgeries? If so, please give details*
What would you like to get out of this session? *
Is there anything in particular you would like to work on? *
Do you have any questions before the session or anything else you would like to add?*
Please select your appointment type:*

Somatic Breathwork Online $188Somatic Breathwork in Person $222Online 3 Session Pack - $511In Person 3 Session Pack - $611
A breathwork or ice-bath session may not be suitable for you if you are pregnant, suffer from a history of epilepsy and seizures, cardiovascular or neurological problems, severe hypertension, mental illness without adequate treatment and support, recent surgery or fractures, acute infectious illness, adverse reactions to vaccinations, bipolar, psychosis, schizophrenia, severe PTSD or severe panic attacks.

People with asthma should bring their own inhaler and consult with their physician before participating.

I understand and acknowledge that I am responsible for consulting my health care provider or doctor in case I have or suspect to be suffering from a severe health problem.

I know and acknowledge that the person facilitating the session is not a doctor or psychiatrist, or a specialist in health care, and that the activities offered are not substitutes for medical or psychological diagnosis or treatment.
The facilitator makes no claims to heal medical or psychological conditions.

I understand and acknowledge that the experience may involve deep breathing and allowing emotions to surface that may be triggering or uncomfortable.

I agree to not use any alcohol or recreational drugs directly prior to the session.

I voluntarily participate in these activities knowing the risks and consequences and agree to assume all consequences, known or not.

By attending this experience, I acknowledge that I have read the above warning agree to hold Samantha Lee Yole and any Co-Facilitators harmless to all liability, death, loss, damages and expenses arising out of or in connection with participation in this experience.
Appointment
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