Please complete the health questionnaire below.  Please remember that during the breathwork sessions, you are always in control of your breathing pattern and you get to choose what feels best in your own body.  If you ever wish to release the breath pattern all together, you can do so at any time.  This is meant to be a gentle but intentional way of shifting any energy that you have been holding in the body.  

PLEASE KEEP IN MIND, this is not intended to replace any medical advice or therapy.  These are guided, supportive sessions using gentle meditative breathwork.  If you’re dealing with severe mental health symptoms, I encourage you to seek specialized medical/clinical support.

Name of Emergency Contact*
Emergency Contact Phone Number*
Have you done breathwork before?*
Have you had OR do you have any of the following conditions? *
If you selected other, please specify. *Enter N/A if not applicable.*
If you answered yes to any of the previous questions, please provide medical clearance from your doctor as active breathwork is not going to be a safe practice for you at this time. However, if you still wish to register you can participate by following the natural rhythm of your own breath as I guide you during the sessions.*
Are you currently pregnant or trying to get pregnant?*
Have you been hospitalized in the last 12 months?*
If you answered yes to the previous question, please provide more details
By checking YES below, you are signing your name and attesting to the truthfulness of your submission. I, as your facilitator, reserve the right to move forward with the breathwork sessions based on the information you've provided*
By checking YES, I understand that breathwork is not a replacement for any other form of therapy or medical professional advice*

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By registering for this series, I agree to receive email updates from Bonnie Koenig of Breathe with Bonnie. I can opt out at any time.