WORK WITH ME 1:1 Start by filling out the form below Personal Info First Name:* E-mail:* Last Name:* Phone Number: Questionnaire What would you like to call in and claim for your first session? Anything you want to release or let go of? Anything you want to focus on in your relationship or career? What feels the most disconnected right now?* Have you ever done Breathwork before? If yes, what was that experience like? Have you been hospitalized in the last 12 months? If yes, please explain* Do you have any unprocessed emotional trauma? If yes, please explain* Is there anything you want to communicate regarding your comfort level or any boundaries during the session? Medical If you answer “Yes” to one or more of the following questions below, you must consult your physician before engaging in Breathwork. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition. Select any health conditions below:*Cardiovascular diseaseAnginaHeart attackHigh blood pressureGlaucomaRetinal detachmentOsteoporosisRecent injury or surgeryAny condition for which you take regular medicationHistory of Panic attacks, psychosis, and disturbancesSevere mental illnessSeizure disordersFamily history of aneurysmsFrequent dizziness or vertigoCurrently pregnant Continue to Sheduling *Disclaimer: I am not a doctor. No claims or promises to “heal” you from your condition. Personal Info First Name:* E-mail:* Last Name:* Phone Number: Questionnaire What would you like to call in and claim for your first session? Anything you want to release or let go of? Anything you want to focus on in your relationship or career? What feels the most disconnected right now?* Have you ever done Breathwork before? If yes, what was that experience like? Have you been hospitalized in the last 12 months? If yes, please explain* Do you have any unprocessed emotional trauma? If yes, please explain* Is there anything you want to communicate regarding your comfort level or any boundaries during the session? Medical If you answer “Yes” to one or more of the following questions below, you must consult your physician before engaging in Breathwork. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition. Select any health conditions below:*Cardiovascular diseaseAnginaHeart attackHigh blood pressureGlaucomaRetinal detachmentOsteoporosisRecent injury or surgeryAny condition for which you take regular medicationHistory of Panic attacks, psychosis, and disturbancesSevere mental illnessSeizure disordersFamily history of aneurysmsFrequent dizziness or vertigoCurrently pregnant Continue to Sheduling *Disclaimer: I am not a doctor. No claims or promises to “heal” you from your condition.
