All new clients must fill the forms below PRIOR to your appointment.Thank you Medical Questionnaire Submit Medical Questionnaire Date MM DD YYYY Name * First Name Last Name Email * Phone (###) ### #### Emergency Contact's Name First Name Last Name Emergency Phone Number (###) ### #### Physician's Name First Name Last Name Physician's phone number (###) ### #### GENERAL Have you ever done breathwork prior to this session? Yes No Has there been an event or experience that you feel open to sharing that could support me, as your facilitator, support you in a deeper way? Have you been hospitalized in the last 12 months? YES NO If you answer YES to the previous question, please explain Have you had OR do you presently have any of the following conditions? (Check all that apply) Angina Cardiovascular disease Heart Attack High Blood Pressure Glaucoma Retinal detachment Osteoporosis Seizure disorders Recent Injury or surgery Any conditions for which you take regular medications History of panic attacks History of psychosis Severe untreated mental illness Family history of aneurysms Frequent dizziness or vertigo Are you currently pregnant Other None of these Important If you have answered "Yes" to one or more of the above questions, you must consult your physician before engaging in meditative breathwork. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition. Comments Signature By typing your full name here, you attest to the truthfulness of your statements and answers. We reserve the right to determine eligibility for engagement and participation in our sessions based upon the answers given.* Thank you! Release of Liability Submit New Form Name * First Name Last Name Email * I agree that my participation in the session is entirely voluntary and that I assume any risk associated with participation. Any actions or lack of actions taken by me, such advice, is done solely by choice and responsibility and any harm, injury, or loss that may occur to me or my property as a result of my participation in the program, is neither the responsibility nor liability of Source Within You LLC (SWY) or trained Facilitator Annete Marquez* I agree I do not agree I understand that during the session, I may be photographed or videotaped for marketing purposes. I promise to take utmost care of any footage of you and will pledge that this footage will only be used for marketing and not distributed in any way, within the boundaries of the law that applies to this agreement. If for whatever reason I wish to use footage outside of session purpose, I will inform you and get your permission first. By agreeing to this statement, you agree to these terms.* I agree I do not agree I understand that breathwork is not a substitute for counselling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment, and I will not use it in place of any form of therapy. I recognize that breathwork requires emotional, physical, and mental effort, exertion, and behavioural experimentation on my part, which may cause physical, mental or emotional injury. I fully acknowledge and take full responsibility for all the risks involved. I understand that it is my responsibility to consult with my health care provider prior to participating in the program.* I agree I do not agree In the event that I am injured, I agree to assume any financial obligation, either through my personal health insurance or through some other means for any medical costs I incur. Source Witnin You LLC (SWY) and Facilitator assume no responsibility for any medical expenses, injury or damage suffered by me in connection with the use of any facilities or services in connection with the session.* I agree I do not agree In consideration of my participation in the session, I HEREBY GENERALLY RELEASE AND PROMISE TO INDEMNIFY, DEFEND AND HOLD HARMLESS SOURCE WITHIN YOU LLC AND Facilitator AND THEIR RESPECTIVE AGENTS AND EMPLOYEES (THE "RELEASE PARTIES") FROM ANY LIABILITY WHATSOEVER. I will reimburse SWY and Facilitator for any damages, reasonable settlements and defense costs including attorney's that they incur because of any such claims made against them. I agree that the terms of this agreement including the indemnification obligations in this paragraph will be binding on my estate, my personal representative, executor, administrator or guardian will be obligated to respect and enforce them. This RELEASE does not extend to claims for gross negligence, intentional or reckless misconduct or any other liabilities that applicable law does not permit to be excluded by agreement.* I agree I do not agree I agree that the purpose of this agreement is that it shall be an enforceable RELEASE OF LIABILITY AND INDEMNITY as broad and inclusive as is permitted by Texas law. I agree that if any portion or provision of this agreement is found to be invalid or unenforceable, then the remainder will continue in full force and effect. I also agree that any invalid provision will be modified or partially enforced to the maximum extent permitted by law to carry out the purpose of the agreement.* I agree I do not agree I understand that this is a contract that affects my legal rights, and I have read and understood this form and all its contents. I voluntarily agree to the terms and conditions stated above.* I agree I do not agree Thank you!
