Participant Acknowledgment, Consent & Health Screening

Please read this section carefully before completing the health screening below.

Acknowledgment & Assumption of Risk

I understand that Rebirth Breathwork, Shamanic Breathwork, Water Rebirth, and Water Healing journeys are powerful experiential practices that may support deep self-exploration, emotional processing, and transformation.
These experiences may involve conscious breathing, music, movement, water-based support, energetic facilitation, and altered states of awareness, and can at times bring forward intense emotional, physical, or energetic responses.
I acknowledge that possible effects may include, but are not limited to:
  • Dizziness, tingling, light-headedness, or changes in breath
  • Emotional release or catharsis
  • Temporary changes in consciousness or perception
  • Increased heart rate, body temperature, or energy sensations
  • Physical sensations related to floating, support, or water immersion (where applicable)
I understand that these practices are voluntary, choice-based, and that I may pause, modify, or stop my participation at any time.

Medical & Psychological Considerations

I understand that breathwork and water-based healing practices are not recommended for certain medical or psychological conditions, including but not limited to:
  • Cardiovascular disease, uncontrolled high blood pressure, or history of stroke
  • Epilepsy or history of seizures
  • Glaucoma or detached retina
  • Severe or unmanaged mental health conditions (e.g. active psychosis, schizophrenia, manic episodes)
  • Pregnancy
  • Recent surgery, serious injury, or significant medical conditions
  • Conditions that significantly affect breathing, consciousness, or nervous system regulation
I understand that in some cases, medical or therapeutic guidance or clearance may be recommended prior to participation.

Disclosure & Personal Responsibility

I confirm that I have honestly and fully disclosed any relevant physical, emotional, mental, or medical information that may impact my participation.
I understand that the facilitators, assistants, and representatives of Journey of Self act as guides and space holders only, and do not diagnose, treat, or replace medical, psychological, psychiatric, or therapeutic care.
I acknowledge that these sessions are not a substitute for professional healthcare, and that no specific outcomes are guaranteed.

Release of Liability

I voluntarily assume full responsibility for my participation and for any risks, discomfort, or experiences that may arise.
I hereby release and hold harmless Journey of Self, its facilitators, assistants, agents, volunteers, and associated individuals or organisations from any claims, liabilities, or damages arising from my participation, including those related to the premises, activities, or facilitation of the session.

Confidentiality & Consent

I agree to respect the confidentiality of other participants and acknowledge that I am responsible for my own wellbeing during and after the session. I will communicate any discomfort, concerns, or need for support to the facilitator as they arise.
By signing below, I confirm that I have read, understood, and voluntarily agree to the terms outlined above, and consent to participate.


Acknowledgement & Consent*
Emergency Contact Name*
Emergency Contact Phone*
Which session(s) are you participating in?*
Do you currently experience or have a history of any of the following? choose all that apply*
If you selected any of the above, please provide details:
Have you ever been diagnosed with, or do you currently experience any of the following?*
Are you currently under the care of a doctor, psychiatrist, psychologist, or other medical or mental health practitioner?*
If yes, please specify the type of practitioner:
If you are currently receiving care from a medical or mental health practitioner, we encourage you to mention your participation in breathwork or water-based healing with them. *please select multiple
Practitioner name (optional):
Clinic or practice name (optional):
Are they aware that you are participating in breathwork or water-based healing sessions?
Is there anything your facilitator should be aware of to support your safety or integration?
*This information is collected for safety and support purposes only. You are not required to provide practitioner details unless you feel it is relevant.
Are you currently taking any medication that may affect breathing, consciousness, nervous system regulation, or emotional processing? This information is collected to support safety and appropriate facilitation. It does not automatically exclude participation.*
If yes, please share anything you feel is relevant for your facilitator to know:
*Some medications may require additional discussion or medical guidance before participating. In certain cases, participation may not be recommended.
I understand that breathwork and water-based healing may not be suitable if I have certain medical or psychological conditions, and I agree to disclose relevant information honestly.*
Water-Based Session Specific - Are you comfortable in water, able to float with support and swim?
Do you have any concerns related to water, floating, water confidence or being held/supported?
Breathwork Readiness & Consent - I understand that breathwork may involve:*
I understand that this is a choice-based, non-forced experience, and that I am encouraged to listen to my body at all times.
Is there anything that would help you feel safer or more supported during your session?
Physical support preferences:
Energy work consent:*
Declaration [choose both if you agree]*
**By submitting this form, you confirm that this acknowledgement serves as your digital consent.**