Name *

First Name

Last Name

Phone *

Country

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you a history of or do you currently have any conditions *

select all that apply

Heart disease

High blood pressure

High cholesterol

Heart attack

Stroke

Blood clots

Blood disorders

Cancer

Diabetes

Gastrointestinal disorders

Severe or untreated mental illness

Emotional trauma

Major depressive episodes

Sleep disorders

Sleep Apnea

Psychosis or mental disturbances

Suicidal Idealizations

Panic Attacks

Osteoperosis

Frequent dizziness or vertigo

Family history of aneurysms

COPD

Breathing or Lung disorders

Scoliosis or Kyphosis

IBS

Gastrointestinal or Digestive disorders

Seizure disorders

Recent surgery (under a year)

Thyroid disorderd

Obesity

Currently pregnant

Other

None

Are you currently undergoing any therapeutic treatment? *

yes

no

Treatments you have tried (select all that apply) *

Yoga

Talk therapy

EMDR

Psychedelic

Cannabis

Diet/ Nutrition Plans

Supplements (i.e. vitamins, powders, etc)

Prescription medications

Saunas

Cold plunge

Neurofeedback

12-step programs

Chiropractic

Acupuncture

Energy healing (i.e.: Reiki)

Other

N/A

Have you tried breathwork before? *

yes

no

Are you currently suicidal? If yes, please call 911 or 988 Suicide & Crisis hotline immediately *

yes

no

Are you currently taking any medications for mental health purposes? *

yes

no

Are you currently undergoing any major life changes? *

Divorce

Separation

Career change

Moving

Loss in family

Loss in spouse

Loss of job

Illness

Do you frequently experience any mental health issues or emotional distress? *

Grief

Depression

Anxiety

Ruminating thoughts

Difficulty focusing

Fatigue

Emotional Outbursts

Anger issues

Chronic Stress

n/a

Checkbox *

I acknowledge that I must provide a 24 hour notice of cancellation if cancelling to and will receive credit towards a future service if rescheduled 3 months.

Today's Date *

MM

DD

YYYY