Breathwork Health Waiver Name * First Name Last Name Phone (###) ### #### E-Mail-Adresse * Emergency Contact In the event that you may need additional support, who is your emergency contact: First Name Last Name Phone (###) ### #### E-Mail Have you ever experienced breathwork before? If Yes, what is your previous experience ie: integrative breathwork, holotropic breathwork, therapeutic breathwork, conscious breathing, transformational breathwork or rebirthing and with whom and when? What brings you to want to engage in this process at this time? Do you have any concerns or questions about participating in this work? Please note that it is inappropriate to use recreational drugs prior to, or during, Divine Roots Sessions. Breathwork is intended as a personal growth experience. It is a dynamic experience, both simple and powerful and can be accompanied by strong emotional and physical release. To ensure that the Breathwork session is appropriate for you and for you to receive proper support please inform of Divine Roots of any present or prior history with cardiovascular problems, severe hypertension, mental illness, recent surgery or fractures, acute infectious illness, epilepsy or spiritual emergency. If you are pregnant please inform Divine Roots of the current state and stage of your pregnancy. Pregnancy is a very important and sacred time. If you have any questions about whether you should participate, please consult your physician or therapist, as well as the event facilitators, before participating in the Breathwork experience. Please check if you are pregnant you have ever been hospitalized for psychiatric or medical reasons (note details on reverse) you are taking any medications. Which? you are currently in therapy or any support group there were complications at your birth(Caesarian, anesthesia, multiple births, &c) you have attempted or seriously considered suicide (note details on reverse side) you are currently experiencing spiritual emergency you currently have infectious or communicable disease If you are pregnant please note your due date. If you are taking medications please note which. Do you have any history of the following: Cardiovascular disease or heart attack Headaches Family history of strokes High blood pressure Diagnosed psychiatric condition Aneurism Physical illness or injury Epilepsy Recent/current communicable disease Diabetes Glaucoma or retinal detachment Osteoporosis Recent surgery Alcohol or drug abuse Asthma (IF YES, BRING INHALER TO BREATHWORK SESSIONS) If you answered "yes" to any of these questions, please explain with additional detail: Is there anything else about your physical or emotional status that we should be aware of? Please read the following notes I understand that if I am taking any medications or have any medical conditions such as, but not limited to: Schizophrenia, bipolar disorder or psychosis, epilepsy, heart conditions, COPD, delicate pregnancy, high/very love blood pressure with fainting history, PTSD, or recent major surgery that I must advise the facilitator before the session. I also understand that even though I have been accepted as a participant/client , I am responsible for any consequence resulting from any breathwork session that I do with Divine Roots. Divine Roots is not a substitute for consulting your doctor or medical care provider. In the event of known medical conditions, I certify that I have consulted a health professional regarding any condition ( physical, mental or emotional) that could interfere with my judgment, or affect my health in any way during or after the session. In-person sessions only – I am aware that appropriate touch may be used for the purpose of supporting my wellbeing and comfort. Divine Roots Health Waiver Statement (2023) I hereby confirm that I have read and understood the above information and have answered all questions completely and honestly and have not withheld any information. My general health, other than as noted, is good. I will not use alcohol or recreational drugs during Divine Roots Sessions or Ceremonies * Yes I have Name & Date * Vielen Dank!
