Breathwave intake form

Name

Emergency Contact Name and Phone Number

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, except where required by law or where there is a risk of harm to myself or others.

I authorize Breathwave to collect my personal and medical information as described above.

Physical Health: Have you ever been diagnosed with heart-related conditions (e.g., heart disease, high blood pressure, arrhythmia)?

Yes

Physical Health: Have you had any surgeries or significant medical procedures?

Yes

Physical Health: Do you have any injuries, chronic pain, respiratory conditions, or other physical limitations that may affect participation?

Yes

Physical Health: Please list any other current medical conditions that we should be aware of.

Mental Health: Have you experienced or received treatment for mental health conditions (e.g., anxiety, depression, panic attacks, trauma-related conditions, psychosis)?

Yes

Mental Health: If yes, please share any relevant history you feel comfortable disclosing.

Personal 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.

Current Practices: Do you currently exercise, practice meditation, breathwork, or other mindfulness-based approaches? If applicable, which practices, therapies, or healing modalities are you receiving?

Sensitivities: We want to support you as fully as possible. Please share anything else that feels important, like medications, preferences, or anything that would help us hold the space for you.

Additional Information: We want to support you as fully as possible. Please share anything else that feels important — medications, preferences, or anything that would help us hold the space for you.

Self-Responsibility Agreement: I acknowledge that breathwork is an active self-healing practice that directly influences my physical, mental, emotional, and energetic states. I understand that conscious breathing can bring thoughts, beliefs, sensations, symptoms, and emotions into awareness, and I accept full responsibility for my own experience and responses throughout the process. I recognize that breathwork may involve altered or non-ordinary states of consciousness. I understand that I can adjust my pace at any time to support my safety and well-being. I acknowledge that sensations such as changes in heart rate, body temperature, tingling, muscle tension, or emotional release may occur, and that potential benefits may include deep relaxation, improved rest, digestive changes, and general shifts in physical or emotional health. I confirm that I am participating free from the influence of alcohol or non-prescribed drugs, and that I have truthfully completed the required intake process, disclosing any relevant physical, mental, or psychological conditions. I agree to inform the facilitators of any health considerations requiring additional care or attention. I accept that all activities are undertaken at my own risk. To the fullest extent permitted by law, I release and hold harmless the facilitator and/or venue providers, and associated parties from any claims arising from my participation. By agreeing below, I affirm my willingness to engage in this practice with personal accountability, self-awareness, and respect for the shared learning environment.

Yes, I hereby consent to my participation

Date: By indicating the date, I confirm that the information provided is accurate to the best of my knowledge and that I will inform the facilitator of any relevant changes in my health status.

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

Yes, I agree to receive communications from Breathwave.

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