🌿 Breathwork Intake & Health Screening Essential Journey

🌿 60 Minute Essential Journey 1:1

Duration: 60 Minutes | Investment: $65

What to Expect:

Preparation & Intentions: Grounding discussion and gentle breath orientation.

Active Breathwork: ~30–35 minutes of Conscious Connected Breathing to clear energetic blocks and release somatic tension.

Integration: Restorative quiet space and closing integration guidance.

1. Client Information

Full Name

Email Address

Phone Number

Emergency Contact Name & Relationship

Emergency Contact Phone Number

I confirm that I am 18 years of age or older.

2. Breathwork Experience & Focus

Have you practiced conscious or active breathwork before?

Never / First time

A few times

Regular practice

If yes, what style(s) have you practiced?

What is your main focus or intention for your session today? (Select all that apply)

How would you rate your current daily stress level?
Scale: 1 (Very Calm) — 10 (Extremely Stressed)

3. Health & Safety Screening

Active breathwork techniques involve intentional altered breathing patterns that dynamically affect the nervous, cardiovascular, and respiratory systems.

Do you have or have you recently experienced any of the following conditions? (Select all that apply)

Is there anything else regarding your physical health or breathing capacity I should know before our session?

4. Medical Disclaimer & Liability Acknowledgment

Medical Disclaimer:

Victoria Metivier / Embodied Breath with Victoria is not a licensed medical doctor, psychiatrist, or psychotherapist. Breathwork, energy healing, and coaching practices are complementary holistic wellbeing modalities intended for self-care and personal development. They do not constitute medical, psychological, or psychiatric diagnosis, advice, or treatment.

Assumption of Risk

Assumption of Risk: I understand that breathwork involves active, intentional changes to my breathing pattern that may evoke strong physical releases, emotional responses, or temporary sensations such as tingling, lightheadedness, or emotional expression. I voluntarily choose to participate with full knowledge of these potential reactions and assume all risks associated with my participation.

Waiver & Release of Liability: I hereby release, waive, and discharge Victoria Metivier and Embodied Breath with Victoria from any and all claims, liabilities, or demands for injury, loss, or discomfort arising out of or related to my participation in breathwork, coaching, or energy healing sessions.

Required Disclaimer Checkboxes

I have read and understand the Medical Disclaimer above. I acknowledge that these sessions are not a substitute for professional medical diagnosis, treatment, or mental healthcare.

I confirm that the health information provided in this form is accurate and complete. If I checked any contraindications above, I confirm I have consulted with a medical professional or agree to participate using gentler, modified breathing patterns.

Step 4: Electronic Signature & Date

Billing & Cancellation Policy

I understand that session fees are non-refundable for cancellations made with less than 24 hours' notice or for no-shows. Cancellations made with at least 24 hours' notice may be rescheduled or refunded.

Signature (Draw below)

Signature