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Breathwork Intake Questionnaire

A short form to support Skye in supporting your Breathwork practice. None of the information you provide will be shared.

(if you'd like to share)
Do you have prior experience with breathwork? If so, tell me a bit about it.
  • {name}
For your safety: Are you pregnant, epileptic, living with a serious cardiovascular disease or have you experienced a recent brain aneurism or stroke?
Those who identified with the above should not engage in the style of breathing we used in this class. I am happy to schedule a 1:1 session to explore alternative Breathwork techniques with you.
For your safety: Do you experience any of the following: panic attacks, high anxiety, sever trauma, high blood pressure, migraines, asthma?
The manipulation of the breath brings about changes in blood pressure, blood flow, and our emotional states. It can bring up feelings of uncertainty or distress. Those who experience the above may be more sensitized to triggers. Having this information helps me prepare to facilitate a supportive space for you, to the best of my ability.
  • Panic Attacks
  • High Anxiety
  • Severe Trauma
  • High Blood Pressure
  • Migraines
  • Asthma
Would you like to provide any additional context or information about your answer to the previous two questions
If you have any questions or medical concerns about practicing breathwork, please reach out to me at SkyeKowaleski@gmail.com. I may suggest that you consult a medical provider before engaging with this style of breathwork.
  • {name}
Would you like to receive information about future breathwork sessions
I send a weekly email updating and reminding participants about current offerings. Please indicate if you'd like to be added to that list.
Do you have any access needs you'd like to share?
  • {name}
Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Emilyn A. Kowaleski from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with this workshop
I am insured through Energy Medicine Professional Association (under my legal name) and am required to ask participants to agree to this clause before engaging in sessions.

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