Breathwork Consent Form

Personal Info

Scope of Practice

My name is Jean-Marie.  I am a Breathwork & Licensed Tantra Massage Therapist, & Energy Worker.  It is my honor to hold space for clients & guide them through what is coming up on the journey to healing.  With breathwork long lasting healing and transformation is possible and I am so grateful you are open to this experience.

I am not a therapist, psychologist or doctor of any kind and I do not diagnose or treat diseases.   I am a licensed bodyworker, energy worker and student in the school of life.  It is my goal to facilitate energetic healing with breathwork to help clients discover, release and process energy to feel empowered.

Breathwork is a form of guided meditation using specific breathing patterns to drop deeply into the body to access energy, thought patterns and emotions.   This active meditation with the 2-part breath floods your system with oxygen allowing for your thinking mind to relax and fall into a trancelike state. Being in this state accesses the unconscious mind and any patterns of thinking, stuck energy or experiences to come forward; allowing processing and healing.

This type of breathwork is done lying down and the breath is done exclusively through the mouth.

It is a deep inhale into the belly followed by a shallow inhale into the chest; then an exhale.

As a trauma informed facilitator I will be holding the energetic space, guiding the client through any feelings and emotions that come up, prompting curious questions, encouraging and empowering you to feel your way through to the healing you desire.

Common things you may feel during breathwork:

• Body tingling/buzzing

• Hot or cold flashes

• Energy flowing through your body

• High emotions

• Crying/Tears

• Dry mouth

• Past memories

• Visualizations

• Light hand or foot cramps

• Deep relaxation

• The urge to shake, move, yell (this is all a way to move energy)

Please consult your medical care practitioner prior to practicing breathwork if you experience any of the following:

• high blood pressure

• hypertension 

• cardiovascular disease 

• epilepsy 

• ulcers 

• aneurysms 

• detached retina 

• if you’re pregnant or think you may be pregnant

• bi-polar disorder 

• recent hospitalization from any psychiatric disorders 

• schizophrenia

• seizures 

• use of blood thinners

• lung disease

Liability Waiver & Release Form

 understand that Breathwork utilizes therapeutic conversation, dynamic breath, essential oils, guided meditation, laying on of hands, and music, and may result in intense emotional release and strong physical experiences. Because this process may trigger an emotional reaction, I understand that any issues arising from my voluntary participation in Breathwork may require additional therapeutic support. I understand that Breathwork is designed to enhance the overall quality of life and is in no way a substitute for psychotherapy.  I  hereby affirm that I am in good health and able to participate in this activity. I do not have any physical or mental conditions which would impair my ability to engage in this activity or would endanger my health during this Breathwork activity, or would cause any risk or harm to myself or other participants. I understand that Breathwork is not medically supervised. If I have any questions or concerns about whether or not a particular activity is appropriate to my current health status, I understand it is my responsibility to ask my doctor before I participate in such activity. Please note that it is inappropriate to use recreational drugs prior to, or during breathwork. I agree to indemnify and hold harmless Jean-Marie/Soul Synergy from and against any and all claims and expenses, including attorney fees, arising out of my participation in this Breathwork activity.  Please note that it is inappropriate to use recreational drugs prior to, or during breathwork. 

By signing & submitting this form I agree to indemnify and hold harmless Jean-Marie/Soul Synergy from and against any and all claims and expenses, including attorney fees, arising out of my participation in this Breathwork activity. In consideration of my participation in this Breathwork activity, I hereby waive and release Jean-Marie/Soul Synergy from any and all claims, costs, liability, and expense for any injury, loss or damage whether known, anticipated, or unanticipated arising from my participation in Breathwork. This Waiver and Release of Liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.  

By signing below I affirm that I have read and understand the information on this consent form.

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