Intake Form | Kat Genc

New Breathwork Client Intake Form

Safety is of utmost importance. Due to the nature of this work and Breathwork, there are certain contraindications that may prevent you from being able to attend, or may require additional information and changes to your session. The following questions are designed to assist us with your session. Please answer as honestly as you can. It will take less than 10 minutes to complete. Please ensure you complete all the fields marked with an asterisk *

All information is held in strictest confidence. No information is disclosed or shared without your written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose other than the fields marked with an asterisk *

First name

Last name

Current Age

Address

Phone

Occupation

Emergency Contact Name and Number

Relationship to Client

Current medications/supplements and reason for taking:

Have you done Breathwork before? If so, please describe your experience

Do you have any experience with any other somatic therapies or emotional release work?

List significant traumas, surgeries, accidents in the last 5 years?

Client Medical History

Please complete the following questionnaire to the best of your knowledge. Further questions may be asked by the facilitator regarding the information provided here.

Are you currently pregnant?

If you ticked any of the above, please explain further:

Do you have any other medical conditions that could affect your breathing or your ability to participate in breathwork?

Have you experienced any recent major life events or changes that may impact your physical, emotional or mental state?

Are you comfortable with exploring emotions that may arise during breathwork sessions?

Do you have any allergies or sensitivities to smoke (burning sage), scents or essential oils that may be used during the session?

Have you ever experienced a panic attack or an anxiety attack? If so, when and please describe:

Do you have a history of trauma or PTSD? If yes, please describe:

Are you currently seeing a psychotherapist or mental health professional? If yes, please provide details of the nature of this care; for what purpose, for how long and outcomes:

Do you currently smoke tobacco? If yes, how often?

Do you currently drink alcohol? If yes, how often?

Have you taken any recreational drugs or plant medicines in the past week? If so, what have you taken and how frequently do you take?

Have you ever experienced any 'bad trip' with psychedelic drugs? If so, when, and what was your experience?

I am comfortable with lying down and/or sitting in stillness for an extended period of time?

Are you comfortable with physical touch/body work during your session

Yes

Do you have any specific concerns about breathwork or the session itself?

Is there anything your would like the facilitator to know about your personal or cultural background that may be relevant to the session?

Is there anything else you would like your practitioner to know before your session?

What are you hoping to gain from your breathwork session or do you have any specific goals or intentions?

I have completed this form to the best of my knowledge and will inform my facilitator of any change in my physical, mental or emotional health

I understand that a Breathwork facilitator cannot diagnose illness, disease, or any other medical, physical, or emotional disorders nor perform any spinal manipulations. I am responsible for consulting a qualified physician for any physical ailments.

I understand that Breathwork is a therapeutic health aide and is non-sexual. I also understand that any illicit or sexially suggestive remarks or advances made will result in immediate termination of the session, and I will be liable for payment

I understand that if I arrive late, my session will end at the originally scheduled time so the client following me is not penalised and full payment will be due

I understand a session does not guarantee changes in my behaviour or lifestyle, that I am responsible for interpreting, integrating and taking action on awareness from the session

Please read our terms and conditions, liability waiver and release form available at: Terms and Conditions

I have read and accepted the above full terms and conditions, liability waiver and release form

Cancellation and Rescheduling Policy

1:1 Sessions

Appointments are reserved especially for you. A minimum of 24 hours’ notice is required to reschedule or cancel a 1:1 session. Cancellations, rescheduling requests made within 24 hours of the scheduled session, or missed appointments will be charged at 100% of the session fee.

Group Sessions & Events

All group session and event bookings are final. Cancellation requests must be submitted in writing to hello@katgenc.com

Cancellations requested more than 7 days prior to the event are eligible for a 50% refund.

Cancellations requested within 7 days of the event will forfeit the full ticket cost.

Tickets may be transferred to another person with prior written notice.

No refunds are offered for change of mind, missed sessions, or advance payments made for 1:1 sessions or group sessions.

I have read, understood, and agree to the cancellation and refund policy for 1:1 sessions and group sessions as outlined above.

Please sign below to acknowledge that you have fully read, received and understood the details in this form

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