Breathwave intake form

Welcome to Breathwave!

Before we begin, we'd like to learn a little more about you.

This intake form helps us ensure that your experience is safe, supportive, and tailored to your needs. All information shared here is strictly confidential and will only be used to better support you on your journey. Please take your time and share only what feels comfortable.

Name

Consent to Collect Personal and Medical Information: I authorize Breathwave and its associated breathwork facilitators to collect my personal and medical information as documented below. In addition, I authorize Breathwave and the associated facilitator to communicate with my family doctor and/or referring doctor if deemed necessary for my benefit and safety. I understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.

1 - Please list any current medical conditions that we should be aware of.

2 - Please list any history of psychological or mental health conditions.

3 - Which practices, therapies, or healing modalities are you currently receiving?

4 - Trauma history: Please list two major traumas or significant challenges in your life, and share what you have learned from these experiences. Please only share what feels comfortable and relevant for your support.

5 - Sensitivities: Please list any sensitivities we should be aware of, such as touch, smells, sounds, music, lighting, or other sensory experiences.

6 - Is there anything else we should be aware of in order to best support you?

Email consent: I agree to receive communications from Breathwave. I understand that I can unsubscribe at any time.

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