Intake Form

Flourish As One- Breath & Wellness

Home
About
Offerings
Blog
Contact
Login

Flourish as One, LLC

Intake Form

First Name *

Last Name *

Phone *

Email *

Emergency Contact Full Name *

Emergency Contact Phone Number *

How did you hear about us?

Have you ever done breathwork prior to this program? *

Yes

Has there been an event or an experience that you feel open to sharing that could support me, as your facilitator, support you in a deeper way?

Have you been hospitalized in the last 12 months? *

Yes

If yes, please explain:

Have you had OR do you presently have any of the following conditions? (CHECK IF YES)

Angina

Cardiovascular disease

Heart attack

High blood pressure

Glaucoma

Retinal detachment

Osteoporosis

Seizure disorders

Recent injury or surgery

Any condition for which you take regular medications

History of panic attacks

History of psychosis

Severe untreated mental illness

Family history of aneurysms

Frequent dizziness or vertigo

Currently pregnant

If you have any other medical conditions that you would like me to know about please explain below:

If you have checked “Yes” to one or more of the above conditions, it is advised you consult your physician before engaging in meditative breathwork. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

By signing here you attest to the truthfulness of your statements and answers. We reserve the right to determine eligibility for engagement and participation in our program based upon the answers given.

Signature *

Clear

Print Name *

Date *

Follow Along

Join our email list for updates, offerings, tips and tricks monthly.

Join email list

NEW

Our Latest Jewelry

20% OFF Entire Wedding Collection

Vivamus suscipit tortor eget felis porttitor volutpat. Praesent sapien massa, convallis a pellentesque nec, egestas non nisi. Curabitur aliquet quam id dui posuere blandit.

Shop Sale

Designer Headphones

£8.00

Earth Friendly Bad

£29.00

Purple Chair

£19.00

Earth Friendly Bad

£25.00

Cutting Board

£87.00

Wooden Table

£42.00

hello@flourishasone.com