Client Intake Form

Please fill out the following form to help us understand your physical condition.

First Name

Email Address

Last Name

Date of Birth

Occupation

What health issues are you looking to get support with during our sessions?

Anxiety

Asthma

Can't Fall asleep / wake up frequently

Depression

Brain Fog

Lethargy

Migraine

Overly Intense

Overly Reactive

Panic Attacks

Shortness of Breath

Sluggish Digestion

Stress

Ungrounded

Comments regarding the type of support you're looking for.

Are you currently getting additional support? *

Yes

No

If yes, please list them here:

What, if any, breath practices have you experimented with in the past?

How is your Sleep? *

Great

Average

Poor

How is your digestion? *

Great

Average

Poor

Anything else you would like to add?

I confirm that all provided information is accurate.

Today's date

Intials for confirmation

Thanks for submitting!

Services

Breathwork isn't just for Freediving! This can help with common Breathing Dysfunctions.

1hr Breathwork - via Zoom
$50+tax

1hr Breathwork - in-person
$65+tax

Back to Top

bottom of page

Client Intake Form

Services

Breathwork isn't just for Freediving! This can help with common Breathing Dysfunctions. 1hr Breathwork - via Zoom $50+tax 1hr Breathwork - in-person $65+tax

Back to Top

Breathwork isn't just for Freediving! This can help with common Breathing Dysfunctions.

1hr Breathwork - via Zoom
$50+tax

1hr Breathwork - in-person
$65+tax