Breathwork Client Information & Liability Waiver Release

First name*

Last name*

Date of birth. (month/day/year)*

Mobile phone number*

Email*

Preferred Method of Contact*

Text Message

City*

Emergency Contact- First Name, Last name, Phone number and Relationship*

Do you consume caffeine? *

Daily

Weekly

Less

Do you smoke tobacco? *

Yes

Do you drink alcohol? *

Yes

If yes roughly how many drinks A WEEK do you consume?

Do you consume drugs recreationally? (Cannabis, LSD, Psilocybin, MDMA, Other)*

Yes

Roughly how much water do you drink per day?*

Medical History

Medical History- List any other medical history not listed above:

Are you currently taking any prescription medication?*

Yes

If 'Yes' please list the name of the medications you are currently taking and for how long, please include any herbal supplements or vitamins:

Prescribing Doctor's Name

Prescribing Doctor's Contact Number

Have you had any surgeries in the past 5 years?*

Yes

If yes, please specify the surgery/surgeries

Family medical history- List any family medical history not listed above:

Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?*

Yes

Therapist Name (First Name & Last Name)

Average #hours of sleep do you get a night?*

Please describe any other experiences you have/had problems with:

Why are you seeking Breathwork?*

What do you hope to gain from Breathwork?*

Any additional comments or concerns?

Breathwork Liability Waiver and Release

This Waiver and Release ("Agreement") is made between ("Participant") and Ahwaken Breathwork LLC, including its officers, directors, employees, agents, and representatives Ahwaken Breathwork LLC . By signing this Agreement, the Participant wishes to join breathwork sessions provided by Ahwaken Breathwork and acknowledges understanding the associated risks.

1. Acknowledgment of Risks:

The Participant understands that participating in breathwork sessions involves certain risks, including:

Physical discomfort like dizziness, tingling sensations, or shortness of breath.
Emotional discomfort, such as the release of repressed emotions or memories.
Potential worsening of certain medical conditions.

The Participant confirms that they have been informed about these risks and have had the chance to ask any questions.

2. Assumption of Risk:

The Participant willingly takes on all risks related to participating in breathwork sessions and agrees that Ahwaken Breathwork will not be responsible for any injury, harm, or damages that may occur during these sessions.

Acknowledgment of Non-Medical Service:
I, Margo Kelm, Ahwaken breathwork LLC, hereby declare that I am not a licensed medical doctor, and the services provided under the name "Ahwaken Breathwork LLC" do not constitute medical treatment, diagnosis, or advice. The techniques and methods utilized in Ahwaken Breathwork are solely intended for personal development, relaxation, and wellness enhancement purposes.

3. Release of Liability:

The Participant releases, waives, and discharges Ahwaken Breathwork, including its officers, directors, employees, agents, and representatives, from any and all liability, claims, demands, actions, and causes of action related to any loss, damage, or injury, including death, that may occur during breathwork sessions, whether caused by negligence or otherwise.

4. Indemnification:

The Participant agrees to protect, defend, and hold harmless Ahwaken Breathwork, its officers, directors, employees, agents, and representatives from any and all liability, claims, demands, actions, damages, costs, and expenses (including reasonable attorneys' fees) arising from their participation in breathwork sessions.

5. Acknowledgment of Contraindications:

The Participant acknowledges being informed about the contraindications associated with breathwork, including but not limited to:

Pregnancy
Cardiovascular conditions
History of seizures or epilepsy
Psychiatric conditions such as schizophrenia or bipolar disorder

The Participant understands it is their responsibility to disclose any medical conditions or concerns to Awaken Breathwork before participating in breathwork sessions.

6. Governing Law:

This Agreement will be governed by and interpreted in accordance with the laws of Hawaii, and The United States of America, without considering its conflict of laws principles.

7. Severability:

If any part of this Agreement is found to be invalid, illegal, or unenforceable, the rest of the Agreement will still be valid and enforceable.

8. Entire Agreement:

This Agreement represents the entire understanding between the Participant and Ahwaken Breathwork LLC regarding breathwork sessions and replaces all previous agreements, whether written or verbal.

IN WITNESS WHEREOF, the Participant acknowledges that they have read, fully understand, and voluntarily agree to the terms of this Agreement. The Participant acknowledges by signing below that they have been truthful regarding their medical history.

Legal First and Last Name*

Participant's Digital Signature (Type Legal First & Last Name)*

The participant acknowledges that by signing they have read, fully understand, and voluntarily agree to the terms of this Agreement*

Dated signed*

Month/Day/Year