Client Questionnaire

Pre Breathwork Questionnaire

Firstly, I want to say thank you for showing up for yourself! The purpose of this questionnaire is to gather information that will help us to dive deep and for you to get the most out of this experience.

Anything you share with me and anything that happens in your session/s will be completely confidential. I can also assure you this is a judgement-free zone, so please feel comfortable to fully express yourself. All of you is welcome here.

Through restorative and activating breathing techniques, the aim of breathwork is to restore the natural flow of energy through the body-mind system. During a session clients are safely guided through shifting stored emotions, altering belief systems that no longer serve them, and/or the completion of anything in the system that has been left unprocessed. During the session, this can look like emotional or physical releases, the feeling of energy circulating throughout the body, and so much more.

If you do not feel comfortable answering any questions, you are welcome to leave them blank or we can discuss them verbally.

Important note: If you are pregnant, have any medical conditions or have had any recent surgeries that a breathwork journey may have an impact on, or if you have a history of serious mental illness or drug addiction, please discuss this with me before completing this form.

Full Name *

Preffered Name

E-mail *

Phone Number *

Address *

Referred by?

Emergency contact name *

Emergency Contact Relationship *

Emergency Contact Phone *

How aligned do you feel in your life right now, with regard to your physical appearance?

How aligned do you feel in your life right now, with regard to your mental state?

How aligned do you feel in your life right now, with regard to your emotional state?

How aligned do you feel in your life right now, with regard to your spiritual state? i.e. do you feel connected to a higher power?

How aligned do you feel in your life right now, with regard to your career aspirations?

How aligned do you feel in your life right now, with regard to your social life?

How aligned do you feel in your life right now, with regard to romance?

Do you currently have any healing and/or goals you're working towards? (Physical, Mental, Emotional, Spiritual)

Do you an intention for the breathwork journey? (doesn't have to be complex)

List allergies to medications or substances: (Please let me know if you are allergic to animals, essential oils, perfume etc for your comfort during Breathwork sessions)

Do you currently have any diagnosed conditions, illnesses or addictions? (If yes, please read the declaration attached to ensure your eligibility for a breathwork journey)

Are you currently taking any medications? (If yes, please read the declaration attached to ensure your eligibility for a breathwork journey).

How would you describe your spiritual or religious beliefs? (if any)

Do you have any experience with breathwork? Or maybe similar journeys with energy healing or plant medicine? (if yes, please specify briefly)

Is there a particular genre of music you enjoy or that you do not enjoy?

Anything else you would like to share?