Name * First Name Last Name Email * DOB * Phone * (###) ### #### Emergency Contact * (###) ### #### Is this inquiry for self, a friend/family member, a small group, retreat or corporate event? * Have you done Breathwork before? If you answer 'YES', please jot down a few notes regarding your experience. * Is there anythiing specific calling you to Breathwork? Do you have specific intentions or outcomes you are looking for? Do you have support post Breathwork? Therapist, coach, familial support, etc. * Are you currently experiencing significant mental or physical distress, dealing with an increase of anxiety &/or depression, a flair-up of a mental health disorder, have thoughts of self-harm or un-aliving? Remember anything you share will be met with compassion and confidence. * Are you currently suffering from any form of addiction, or have in the past? * Do you have any notable health concerns or conditions? Have you read the contraindication list & feel like you meet the critiria for participating in Breathwork? * Are you interested in other offerings from Her Health + Healing, such as 1-on-1 or group Breathwork sessions, classical Pilates, Life & Empowerment coaching, private events, sponsorship, product representation, or other? (Please specify) General availability for 2+ HR session * Would you benefit from financial assistance or plan on paying in full? (Please note pricing starts at $175/1:1 session) How did you hear about Amelia & Her Health + Healing Any other comments, feedback, questions, or anything I should know? Thank you, Amelia will be in touch with you soon to go over your submission!
