Name * First Name Last Name Phone * (###) ### #### Email * Age * Location: Life Situation (children etc) * Current employment: Job / Study / Career / Hours. On a scale of 1 to 10, how would you rate your current stress levels? (1 being low, 10 being high): * Describe any major sources of stress or challenges in your life: * On average, how many hours of sleep do you get per night? * Do you experience any difficulties with sleep? If yes, please describe: * Breathwork Experience: Have you practiced breathwork before? Yes often No A little If yes (or a little), please describe your previous experience with Breathwork: Meditation Experience: Have you practiced meditation before? * Yes often No A little If yes (or a little), please describe your previous experience with Meditation: Do you have any existing medical conditions we should be aware of? If yes, please specify: * Are you currently taking any medications? If yes, please list: * Have you had any recent surgeries or medical procedures? If yes, please provide details: * Are you currently taking any supplements? If yes, please specify: * What are your primary health and wellness goals? * Have you worked with any coaches (mindset, fitness etc) in the past? If yes, please describe your experience. * On a scale of 1 to 10. How would you rate your current fitness level? (1 being low, 10 being high): * Have you ever tried cold immersion techniques before? If yes, what was your experience like? * Have you had any recent fitness assessments or medical check-ups? If yes, please share the results. * Do you have much of a morning routine? If so, what does that look like? * Do you have much of an evening routine? If so, what does that look like? * How do you cope with stress and manage your mental well-being? * What do you hope to get out of this program? Any specific intentions? * Do you have any specific expectations or concerns regarding this programme? * Emergency Name and Contact Number: * By submitting this form, I acknowledge that the information provided is accurate to the best of my knowledge. I understand that the provided information will be kept confidential and used solely for the purpose of tailoring breathwork coaching sessions to my individual needs. * Please type your digital signature: Thank you!
