Name *

First Name

Last Name

Emergency Contact Name *

First Name

Last Name

DOB *

MM

DD

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Do you have a current or past diagnosis of any of the following:

Schizophrenia

Epilepsy

Bipolar

Depression

Anxiety

Vertigo

I understand *

that the Breathwork sessions are being held outdoors on the deck. It might be windy/cold, I will ensure to bring appropriate clothing as well as props I like to feel comfortable (e.g. eyemask, blanket).

I certify that I am in adequate physical, emotional, and mental health to participate in a Breathwork session (If not, please specify on the opposite side). I acknowledge that should this information change, it is my sole responsibility to notify my Breathwork Facilitator (Kerstin Hoefner). I consent to and authorise Kerstin Hoefner to guide me in Breathwork Sessions, which may include sound healing, touch, integration, and coaching support. I understand that Kerstin Hoefner is not a licensed physician or functional breathing specialist and does not dispense medical advice or prescribe the use of any technique as a form of treatment for any physical or psychological conditions without the advice of a physician - either directly or indirectly. As a Breathwork Facilitator, Kerstin Hoefner offers information of a general nature to help clients in their journey toward greater self-awareness, mind-body connection, emotional, mental, physical, and spiritual wellbeing and assumes no responsibility for how I (the client) may use this information. Breathwork is not recommended for people with a personal or family history of epilepsy, seizures, cardiovascular problems including angina or heart attacks, high blood pressure, aneurysms, glaucoma, retinal detachment, osteoporosis, or recent physical injuries, surgery, or illness - particularly involving the brain, mouth, teeth, nose, throat, thyroid, immune system, lymphatic system, lungs, chest, ribs, spine, neck and/or reproductive organs. Breathwork is not recommended for people with a personal history of mental illness, personality disorders, hospitalization for any psychiatric condition or emotional crisis, suicidality or psychosis. Possible side effects may include dizziness, changes in body temperature, tingling, cramping, emotional breakthroughs, feeling physical, mental, energetic and/or emotional triggering and/or vulnerability. The nature of Rebirthing Breathwork has been explained to me and/or is available to me in writing and any questions I had regarding the session(s) have been answered to my satisfaction. I understand that the session may involve risks of complications or injury from both known and unknown causes, and I freely assume these risks. I understand that I have the right to refuse to participate in the session. No guarantee, warranty or assurance has been made to me as to the results that may be obtained. I certify the above information is correct to the best of my knowledge. I agree to adhere to all safety precautions and regulations during my sessions with Kerstin Hoefner. I will not hold her responsible for any errors or omissions that I may have made in the completion of this form.

First Name

Last Name

Date

MM

DD

YYYY