Appliance form

Please fill in the appliance form as preparation to the session.

Name *

E-mailadress *

Date of birth *

What would you like to sign up for? *

What is your intention and/or what would you like support with? *

Do you have any medical conditions (e.g. heart conditions, epilepsy, asthma, high blood pressure)? *

Are you currently under the care of a therapist, doctor, psychologist, or other healthcare professional? If yes, for what? *

Have you ever been diagnosed with a mental health condition (e.g. depression, PTSD, bipolar disorder)? *

Have you experienced panic attacks, severe anxiety, or trauma symptoms in the past? *

Are you currently taking any medication? If yes, which ones? *

Do you have previous experience with breathwork, cacao ceremonies, or similar practices? *

Do you have any allergies or dietary requirements? *

Is there anything you would like me to be aware of to best support you during the session? *

I confirm that I have read and understood the contraindications of Breathwork & Cacao (see the Breathwork & Cacao pages on the website). *

Yes

I understand that participation is at my own responsibility and that I will listen to my body and communicate my boundaries during the session. *

Yes

I agree to the reservation fee of €50 *

Yes

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