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Breathwork Intake Form

Welcome visitors to your site with a short, engaging introduction. 

Double click to edit and add your own text.

Which session calls to you?
Conscious Connected Breathwork — emotional release & deep nervous system reset
Functional Breathwork — breath mechanics, daily regulation & performance
Not sure yet — help me choose
Touch preference
Gentle hands-on touch
No direct contact
No preference — practitioner's discretion
Where are you in your breathwork journey?
Brand new & curious
I've tried it a few times
I'm a trained facilitator / teacher
What's your main focus today?
Do any apply to you? Pregnancy, heart/BP condition, stroke or aneurysm history, epilepsy or seizures, glaucoma/eye surgery, recent surgery/injury, psychiatric condition or mental health crisis, or provider care for these.
Yes
No

Consent & Acknowledgement


By typing my name below, I acknowledge and agree to the following:

– Conscious Connected Breathwork and Functional Breathwork can produce intense physical sensations (tingling, lightheadedness, temporary muscle tightness in the hands or feet, changes in body temperature) and emotional release. These effects are common and generally temporary. –My participation is entirely voluntary. I understand I can slow my breath, pause, or stop at any time for any reason.

– Breathwork is not a substitute for medical or mental health treatment. If I answered “yes” to any question in the Safety Check above, I confirm I have consulted a qualified healthcare provider and been cleared to participate. – I have honestly and fully disclosed relevant health information above.

– I release Confluence Breath and Bodywork, its facilitators, and staff from liability for claims, injuries, or losses arising from my voluntary participation, except in cases of gross negligence or willful misconduct.


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How did you find us?

View full Breathwork Release of Liability, Waiver.

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