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the breathing co

confidential intake questionnaire

First Name

Last Name

Email

Phone

emergency contact name

emergency contact phone

whom shall I think for referring you

are you presently or have you previously done breathwork with a professional?

Yes

No

are you presently or have you previously done guided meditation work

Yes

No

are you presently or have you previously done self development work with a professionl?

Yes

No

top 3 physical ailments

significant and relevant medical diagnosis

top 3 sources of mentail ailment or stress

average hours of sleep per night

hours of work per week

how many hours of play each week

do you like your job

Yes

No

average level of energy

low

moderate

high

what would you like to achieve through the support of my services

is there anything else you would like me to know

the signing and submission of this form is also digital acceptance of the breathing co's policy + consent

found here

valid for the duration of services received

Your Signature

thank you for submitting - i look forward to working with you

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