Personal Details

Email

DOB

Current Self-Reflection

How do you see yourself at this moment?

What is your most negative thought about yourself?

What is your most negative thought about life?

What is your most negative thought about relationships?

What are your major fears, if any?

Have you experienced any trauma through your adult life?

List 10 goals (pertaining to any aspect of you and your life):

Health and Wellbeing:

Do you have any problems with your body now, or recently? If so, describe history of illness:

Any major tensions, pains or symptoms?

Are you on any drugs? If so, what for?

Are you presently under (or have you recently been under) psychiatric care?

Have you had any major surgery or injuries? Please describe

For females, how many times have you been pregnant?

How many deliveries?

Any problem with those births, or children?

Intimate Relationship:

What is your relationship status?

Describe your mate:

What is the state of your relationship with your mate? Any significant problems?

And lingering issues or complications with previous relationships?

Pregnancy and Birth Reflection (of your birth):

Where were you born? (State and Country):

In what facility (hospital, home, in a car on the way to hospital, etc)?

What did your parents or others tell you about your pregnancy?

Were there any complications? Describe if there were:

Do you know anything about the labour?

Was your birth itself normal?

Did your mother have any specific problem at your birth?

• Haemorrhage • Infection • Other • Post-Partum Depression etc

Was your father present at your birth? Was he in the hospital area? If not, where was he?

Any other comments about your conception (were you wanted/unexpected?), pregnancy:

Do you have any siblings? Which child were you (birth order)?

Childhood Reflection:

How would you describe yourself as a child?

Did you have any illnesses during your infancy? If yes, explain:

Did you have any illnesses in later childhood?

Did you have any major emotional traumas as a child? Please explain:

Breathwork Experience:

What type?

If not sure of the name/style describe the process

When was the most recent experience?

What do you want to get out of this experience?