Name *

First Name

Last Name

Date of birth

MM

DD

YYYY

Mobility

What is your level of ease with getting up and down from the floor?

I can easily transition from the floor to standing

I can get up from the floor with a little extra time and effort

I would prefer options that keep me standing or sitting on a chair

Some variations of poses offered can incorporate props such as the wall, a chair, yoga blocks or books, etc.

Please mark all that you have available for the practice.

Chair

Wall space when standing

Yoga strap, belt or hand towel

Yoga blocks, books or small trash can

Blankets or pillows

WAIVER OF LIABILITY: "Practitioner" refers to Breath Therapy and Yoga Practitioner and means Breana Allison and is the released party. Breath therapy and Yoga is the application of the principles and practices to promote health and well-being. Its aim is to eliminate, reduce, and/or manage symptoms that cause suffering; improving function; helping to prevent the occurrence or recurrence of underlying causes of illness; and moving toward improved health and well-being. I understand that a consultation should not be construed as a substitute for medical examination, diagnosis or treatment. I understand that breath and yoga practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because consultations should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile during the session and understand that there shall be no liability on the practitioner’s part should I fail to do so. This consent is applicable for future sessions with the practitioner if a new waiver is not required for participation. I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. I also understand that the practitioner reserves the right to refuse a session to anyone whom she deems to have a condition for which the techniques of Breath Therapy and Yoga are contraindicated. *

I take 100% responsibility for my well-being. I absolve all others, living or dead, present or absent, from any responsibility for my well-being. I agree to keep myself safe, not hurt myself or anyone else. I understand that I will not indulge in any drug or alcohol use before my sessions. I agree to address any fear or resistance that may cause me to want to end before completion of committed sessions. I agree to continue any current protocols advised from my outside health professionals. If I choose to discontinue a protocol, it is first discussed with the health professional and any updates are communicated before the next session. I understand that the practitioner agrees to support and encourage my personal revelation and transformation and will be available for my questions and concerns during the time period of sessions. It is my responsibility to reach out if needed. Since I understand that I am completely responsible for my participation, process and well-being in the sessions, I agree to release and hold harmless the practitioner. I have read and agree to the entirety of the liability waiver.

yes

no

Date of signature *

MM

DD

YYYY