Intake Form | Movement * Breathwork * Cranio

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Please fill out this form to the best of your ability! Thank you so much!

电子邮件地址 *

Name *

Which service are you interested in? *

Movement

Conscious Connected Breathwork | CCB

Craniosacral Therapy

Combo

其他:

必填

What is your motivation for exploring this work? Please expand to any depth that feels appropriate. *

Are you or could you be pregnant? *

Yes

Maybe

Do you have any pre-existing medical conditions? If so, please describe. *

Do you have a heart condition or suffer from high blood pressure? *

Are you diabetic or epileptic? *

Have you experienced recently any major injuries, surgeries, or events that have created additional stress for you? If yes, please describe. Note where you feel this in your body. *

Do you have any allergies? *

Have you struggled previously with mental health or addictions? If yes, please describe. *

What practices or therapies are you currently undertaking? *

Is there anything else that you think I should know? *

I am not a therapist, and most practices that I teach are meant to teach you to feel, to allow emotions, and to breathe them into integration. My point is for us to feel and integrate without attaching to story. Please confirm that this resonates with you. *

Yes

I need more information

I understand that all information shared, all body work, and breath work received form Elisha Jane is a choice on my own behalf. I undertake full responsibility. I understand possible risks and I, and my family, associates, et. al waive any and all liability, now or in the future. Application of any and all practices shared are also agreed to of my own accord and liability. *

Yes

其他:

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