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?

Have you done other types of non ordinary states work? What kind?

What do you do to support your psychospiritual growth?

Please advise if you have ever been diagnosed with PTSD, Severe Trauma or as a veteran in combat:

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

you are taking any medications. Which?

you have attempted or seriously considered suicide

you are currently experiencing spiritual emergency

If you are taking medications that we need to be aware of, please note which.

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?

Have you ever worked with Plant Medicine before before?

If Yes, Please highlight your experiences

Are you allergic to Tobacco or Tobacco products?

Pls note that this ceremony is not recommended for anyone allergic to tobacco or tobacco related products

Please list any allergies that we should be aware of before your Rapeh Ceremony

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)

The medical information which I have provided to Divine Roots is accurate, true and complete as of the date of this form. I have disclosed all known or suspected medical conditions. I agree that I will promptly inform Divine Roots of any additional medical conditions or any changes in the medical information that I have provided, as such additional conditions or changes may arise between the date of this signed waiver and the date of the Experience and the Activities.

Yes I have

Name & Date

Client Intake form

Rapeh Ceremony

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