You're One Step Closer to Your Breathwork Journey!

Congratulations on taking this powerful step toward transformation with Rebirth/Shamanic Breathwork! Before we begin, I just need a little more information to ensure your experience is as safe, comfortable, and supportive as possible.
Breathwork is a deeply immersive practice that can bring up strong physical and emotional responses. This form helps me understand any health conditions or concerns that might impact your session so that I can best support you throughout the process.
Your privacy is always respected, and all information provided is kept strictly confidential. Please take a few moments to complete this form honestly. If you have any questions or need to discuss anything further, don’t hesitate to reach out.
Now, let’s get you ready for this incredible journey inward!





Please fill in the following and click submit at the bottom so I may support you on your journey safely :)

HEALTH AND MEDICAL INTAKE FORM

REBIRTH & SHAMANIC BREATHWORK JOURNEY




HEALTH AND MEDICAL HISTORY
Do you have or have you ever experienced any of the following conditions? (Please tick all that apply)*
Other medical conditions (please specify)
Add here anything additional you would like to elaborate on
CURRENT MEDICATIONS AND TREATMENTS
Are you currently taking any medications? (Select one)*
If yes, please list the medications and their purpose
Are you currently undergoing any medical or psychological treatment? (Select one)*
If yes, please provide details
EMERGENCY CONTACT DETAILS
Emergency Contact Name*
Emergency Contact Phone*
PARTICIPATION AND READINESS CONSENT
I acknowledge that Rebirth/Shamanic Breathwork may involve deep breathing techniques that can trigger strong emotional and physical experiences. I confirm that I have consulted my healthcare provider if I have any concerns about my ability to participate. I understand that this session is not a substitute for medical, psychological, or psychiatric treatment. *

Important Information

Your safety and well-being are my priority. While Rebirth/Shamanic Breathwork is a deeply transformative experience, it can also bring up strong physical or emotional responses. Please take note of the following:
  • In Case of Emergency: If medical assistance is required, an ambulance will be called. You will be responsible for any associated costs, and your emergency contact will be notified.
  • Drug & Alcohol-Free Session: To ensure a safe and effective experience, this session is strictly drug and alcohol-free. Please do not attend under the influence of any substances, as they can interfere with your ability to fully engage in the process and may pose a risk to your well-being. If you arrive under the influence, you will not be able to participate.
  • Medical Clearance: Clearance from your medical professional is advised before participating in any breathwork sessions with Journey of Self.

Mild/Minor Conditions:

You may still be able to participate with some mild/minor conditions using a relaxed, gentle breathing method. Connect with me to discuss your individual case.

Connect with Me:

If you have any concerns or there is something you would like to discuss that is not covered in this form, feel free to contact me at:
📧 bec@journeyofself.com.au
📞 0433 856 053
🚨 Please remember to remind your facilitator of any new or previously discussed conditions prior to your breathwork session, as your safety is our number one priority.