Client Intake Form

Welcome, and thank you for taking the time to complete this intake form. The information you provide here will help me understand you better and ensure that each breath work session is safe, supportive, and tailored to your individual needs.

This form asks for details about your personal background, health history, lifestyle, and any prior experience with breath work or similar practices. Your answers will remain strictly confidential and will only be used to guide our sessions together.

By sharing openly and honestly, you allow me to hold space for you in the most effective way possible, taking into account any areas of caution and supporting your goals for the practice. Please know that there are no right or wrong answers - simply what is true for you.

Take your time, answer as fully as you can.

Filling out forms can sometimes feel a little clinical, so I’ve added the option of soft background music if you’d like some company while you complete this. Simply press the play button above to let the music hold space for you as you reflect and share.

Name

First Name

Last Name

Phone

Country

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Emergency Contact Number

Country

(###)

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Health and Medical Background

Do you have any current health conditions I should be aware of?

Do you experience chronic pain or arthritis?

Have you ever experienced epilepsy, seizures, or fainting?

Have you ever had an aneurysm?

Have you been diagnosed with a detached retina or glaucoma?

Do you live with fibromyalgia, chronic fatigue, ME, or migraines?

Are you currently taking any prescription medications?

Do you have a history of mental illness, trauma, or emotional concerns?

Do you have any experience with breathwork, meditation, or other self-awareness practices?

Do you have any access requirements I should know about?

Personal and Emotional Wellbeing

What brings you to breathwork and what is your intention for starting this journey?

What do you hope to achieve through breathwork?

Are you seeking healing, trauma release, stress relief, personal growth, or something else?

If comfortable, please share details.

What is your central challenge in life right now?

Have you had any significant adverse experiences in childhood or adulthood, such as physical, emotional, or sexual abuse, or neglect?

If comfortable, please share details.

Have you ever been in counselling or therapy for any of the above reasons?

Are there any triggers I should be aware of?

Do you have any fears or concerns about the breathwork process?

Lifestyle Information

What are your current sleep patterns, stress levels, and self-care practices?

What is your daily or weekly physical activity routine?

Do you use any substances such as tobacco, alcohol, recreational drugs, or caffeine, and if so, which ones?

What brings you joy in your life?

Have you used any plant medicine or participated in other transformative experiences?

Are you familiar with different breathing techniques?

End of Session and Integration

At the end of each session, we will create a safe space for integration, providing time to reflect and process. Techniques such as visualisation and grounding exercises may be used to help reinforce the insights gained during the session.