Client Intake & Consent Form

1. Do you have any of the following conditions? (Check all that apply)

Heart conditions or high blood pressure

History of seizures or epilepsy

Asthma or severe respiratory issues

Recent surgery (last 6 months)

Pregnancy

Other:

3. Have you experienced any of the following? (Optional)

Anxiety or panic attacks

Depression

PTSD or history of trauma

Other mental health conditions:

Experience & Intention

4. Have you participated in Breathwork, Reiki, Trauma work, sound healing or any holistic therapies before?

Yes – please share your experience:

Consent & Liability Waiver

Please read and sign below:

I understand that UNA therapy, Holosomatic breathwork, Energy Alchemy, Crystal healing or Sound healing are complementary practices and not a substitute for medical or psychological treatment.
I have disclosed any medical conditions that may affect my participation.
I acknowledge that intense emotions or physical sensations can arise during breathwork, and I am responsible for my own well-being.
I release the facilitator from any liability for any outcomes resulting from my session.