Internal Breathwork Application

Breathwork Intake Form

Please fill out the following form with a bit of information about you.

First Name

Last Name

What drew you to trying breathwork? What are you hoping to get from it?

Do you have previous experience with breathwork? If so, please give me a little information on your experiences

Please review the following list of breathwork contraindications. If you are currently pregnant, breathwork should not be performed at all. For the rest of the contraindications, please consult with your healthcare provider before participating in a breathwork session.

Pregnancy
Cardiovascular disease
Angina
Heart attack
High blood pressure
Glaucoma
Retinal detachment
Osteoporosis
Recent injury or surgery
Any conditions for which you take regular medications
History of panic attacks, psychosis
Severe mental illnesses
Seizure disorders
Family history of aneurysms
Coronavirus or flu-like symptoms

By checking this box, you agree to my Terms and Conditions.

Thanks for submitting! I’m looking forward to our breathwork session!

Breathwork Preparation

I'm so excited about our upcoming Breathwork session. There are a few things we need to take care of before the session.

Please watch this video and fill out the intake form below.