FIRST BREATHWORK SESSION INTAKE FORM

Your story gives us context.
Your body sets the pace.

Please allow about 30 to 45 minutes. You may pause whenever you need to stay grounded. Your responses are confidential and used only to support your work with Sarah Elisabeth.

Basic information

First and last name *Preferred name or nicknameBirthdate *Phone number *

Email address *

Your early relationships

Share only what feels relevant. There is no need to force detail or relive an experience to answer.

My father is… *My mother is… *

Describe your relationship with your father *Describe your relationship with your mother *

Other caregiver(s)Sibling(s)

Describe your relationship with other caregiver(s)Describe your relationship with your sibling(s)

Your lived experienceWhat was it like for you growing up? *What did you struggle with? *What do you feel you are still holding onto? *How do you currently feel about yourself and your life? *

Where you are now

1 means deeply out of alignment; 10 means deeply aligned with how you want to live.

Physical alignment *Mental alignment *Emotional alignment *Spiritual alignment *

What are you currently navigating? *What healing or goals are you working toward? *If you could leave our work with one outcome, what would it be? *How would you describe your spiritual or religious beliefs? *Are there loved ones who have passed that you still feel connected to?Anything else you want Sarah Elisabeth to know?

Health and emergency informationList all medications and supplements you currently take *List diagnosed physical or mental-health conditions, recent injuries or surgeries, and current or past substance-use concerns *

Emergency contact name *Relationship *

Emergency contact phone *

Sensitive health details are saved in Sarah Elisabeth’s private dashboard; the notification email does not include your full answers.

Your story gives us context.Your body sets the pace.

Your story gives us context.
Your body sets the pace.