HOW ARE
YOU

HELP ME TO GE TO KNOW YOU BETTER

First Name

Last Name

Email

Phone

Street Address

Street Address Line 2

City

Postal / Zip code

Birthday

Who would be your emergency contact, and what is your relation to that person?

Emergancy contact number

Are you currantly pregnant?

First trimester

Second trimester

Third trimester

Do you have any of these conditions?

If any of the above point is true for you, would you kindly tell me a bit more about it?

Are you currently experiencing any other medical conditions?

Have you been in any form of therapy before? If so, which one, and how did it help you on your path?

Are you taking any form of medication? If so, please specify.

Do you regularly use alcohol, tobacco products, or any other recreational drugs? If yes, please specify.

Do you engage in regular sports or physical training? If yes, please specify the type and frequency.

Have you participated in any form of meditation or mindfulness-based training? If yes, please provide details.

Do you have any prior experience with breathwork or breathing exercises? If yes, please provide details.

What activities do you engage in for recreation and enjoyment? Please specify.

How is your relationship with your parents?

Do you have any siblings? If yes, what is your birth order among your siblings?

How is your relationship with your siblings?

Are you married/ divorced?

Do you have kids? if so, how many and what age?

What is your current concern? Why would you like to start the sessions with me?

Is there anything else you would like me to know about you, which enables me to support you better?

I agree to take full responsibility of my health and well-being.