Intake Form - beathwork mit recha

Breathwork Intake Form

Please fill out this questionnaire before our first session so I can get a sense of you and your interest in a breathwork session with me.

All information will, of course, be treated confidentially and will not be shared with third parties.

TEIL 1: ZU DEINER PERSON

First and Last Name

E-Mail Address

Mobile Phone Number

Address and tax number/ VAT (in case of need for an invoice)

Date of Birth

Profession of Work

Emergency Contact (Name and Phone Number)

How did you find out about conscious connected breathing and me?

PART 2: YOUR BACKGROUND
In this section, you will have the opportunity to provide additional information about your personal history and life. While all questions are optional, the more context you share, the better I can tailor the Breathwork experience to meet your needs.

Why are you interested in trying Breathwork?

What do you hope to take away from the session?

Please list any medication that you are currently taking and why:

If you are a woman: Are you currently pregnant?
YesNo

Do you have any allergies and if so, please clarify:

Do you suffer from seizures (epilepsy)?

Did you have an heart attack, specifically in the last six months?
YesNo

Do you have any other heart conditions? If so, please clarify:

Did you have a thrombosis in the last six months?
YesNo

Do you suffer from a neurological disease? If so, please clarify:

Please list any (recent) injuries, surgeries or acute physical pain that you currently experience:

Do you have a mental illness? If so, please clarify. Have you worked with a psychotherapist in the past or do you work with one currently, and if so, why?

Do you have someone to support you emotionally if something significant happens in or after our session?

Do you currently work with any practitioners of alternative healing modalities, and if yes, what are the reasons for doing so?

Please check any symptoms that apply to you:
StressAnxiety and/or Panic attacksSleeping issuesNeck and/or Back painMuscle tensionJoint painChronic FatigueDigestive issuesCardiac or circulatory issuesGlaucoma / detached retinaTrauma (Physical / Emotional)Other

PART 3: AGREEMNET
In this section, you'll be asked to agree to practical guidelines aimed at establishing a safe and confidential environment for your Breathwork experience.

I am aware that all information I provide will be treated confidentially and will not be passed on to third parties.
I agree

I am aware that my facilitator has no medical background and cannot and will not make any promises of healing to me.
I agree

I understand that my facilitator is trained in a variety of bodywork techniques and that I can object at any given moment if I do not wish to receive (any more) physical touch or bodywork.
I agree

I know that I alone am responsible for my experience and that my facilitator merely provides me with the framework to experience my thoughts & feelings on a deeper level.
I agree

I will take good care of myself after the session and will take responsibility for asking for help & support from friends/family or my facilitator if I need it.
I agree

I am aware that appointment must be canceled at least 48 hours in advance to find an alternative date, otherwise the full session price is due.
I agree

I confirm that all information provided by me is correct and true.
I agree