Breathwork- New Client Form
If it's your first time breathing with us, please take a few minutes to complete this form before your first session. All information remain strictly confidential. If you have any further questions please email: clem@casafinawellness.com
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Email address *
Full Name *
WA Phone number *
Describe yourself in 3 words *
What are you struggling the most in your life currently?
 *
What do you desire to get out of this session? *
Date of Birth:
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Have you experienced any type of breathwork or other breathing practices before? *
No previous experience is required.
Are you familiar with this line of work? *
Please state what other events or ceremonies you have participated in previously.
Are you able to lay down for about 50 mins? *
If no, please describe
Do you have any health issues? *
Please list current medication and/or medical alternative treatments.
Do you have any heart problems? *
Are you pregnant? *
If yes, please state how many weeks.
Are you working with any of the following: *
Glaucoma, uncontrolled high blood pressure, cardiovascular issues such as angina, detached retina, previous heart attack or stroke, severe PTSD or trauma, diagnosed aneurysm in the brain or abdomen, uncontrolled thyroid conditions or diabetes, asthma, epilepsy, stomach ulcers, history of bipolar disorder or schizophrenia, or any psychiatric hospitalisation or emotional crisis within the past 10 years?

If yes, please provide an overview as this may mean not being able to participate in session.
Do you have any questions or concerns about participating in this work?
How did you hear about me and this form of breathwork?
Would you like to be added to the mailing list to find out about upcoming sessions online and in person? *
I acknowledge that I am voluntarily participating in the breathwork session(s) and I understand that the practice of breathwork may bring up emotions, feelings and physical sensations that can be intense and potentially uncomfortable. I take full responsibility for my participation in these sessions and any consequences that may arise from them.

I understand that it is my responsibility to communicate any discomfort, pain, or other concerns to one of the facilitators before or during the session(s). I also understand that I am in control and the right to stop or modify my participation in the session(s) at any time.

I am happy to continue with the upcoming session(s):
 *
Thank you
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