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Breathwork Intake Form

We kindly ask that you complete the following questions as thoughtfully and accurately as possible. Your responses will help your Blink therapist understand and support your needs ahead of your session. All information shared will remain strictly confidential.

What health issues are you looking to get support with during our sessions? *
Are you currently receiving any mental health support (e.g. therapy, counseling, medication)?
Yes
No

Breathwork

Have you practised breathwork before?
Yes
No

Final Confirmation

Consent to participate

I understand that breathwork can involve physical movement and emotional exploration, which may bring up both physical and emotional responses. I am choosing to participate voluntarily and acknowledge that I am responsible for listening to my body and honouring my limits throughout the session. I agree to communicate openly with my Blink therapist if I experience any discomfort—physically or emotionally—so that the session can be adjusted to best support me. I confirm that I’ve shared accurate and complete information about my health to help create a safe and supportive experience.

Please click below to confirm that you’ve read and agree to the above information
I agree

What Our Clients Say

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