Beth Maiden

Breathwork, dance & somatics

Please complete the form below.

All answers will be kept confidentially and will not be shared with anybody, except in those circumstances described in our agreement.

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Full name *

Email *

Date of birth *

Address *

GP name and address *

Emergency contact *

Please give their name, phone number, and relationship to you.

Have you tried breathwork before? *

If so, please give a brief description of your experience in working with your own breath.

What do you hope to gain from our sessions together? *

Do you struggle with your mental health? *

If you answered yes above, please tell me a little more in the next section so I can ensure our sessions will be safe and appropriate for you.

Tell me more

Do you experience any of the following? *

Heart/circulatory issues, e.g. high or low blood pressure
Respiratory, lung or sinus issues
Nervous system disorders
Autoimmune conditions
Muscular/skeletal conditions, e.g. chronic or acute pain, pulled muscles or broken bones
Eye conditions, e.g. glaucoma
None of the above

If you ticked any of the boxes above, please tell me more in the box below so I can ensure sessions are safe and appropriatre for you.

received, you the

Tell me more?

Are you pregnant or trying to conceive? *

Anything else I need to know?

I confirm I have received, read and agreed to the Client Agreement. *

Please contact me if you have not received this or wish to discuss anything within the agreement.

beth@bethmaiden.com