← BackNew clients

Registration form.

A few details before your first session — they help Jon prepare, and keep the work safe. It takes a minute or two.

First Name*

Surname*

Email Address*

Date of Birth*

Phone Number*

GP Phone Number

Emergency Contact Phone Number*

Do you have prior experience of breathwork?*

Do you have experience of spiritual or psychological work?*

What prompted you to book this session?

Are you comfortable with the appropriate use of touch during the session?*

YesNoI'd like to discuss this first

Are you comfortable being worked with on an energetic level during the session?*

YesNoI'd like to discuss this first

Waiver & Informed Consent

Breathwork can produce profound physical, emotional, and psychological responses, including but not limited to: tingling or numbness, spontaneous movement, emotional release, altered states of awareness, and the surfacing of unconscious material.

By participating you acknowledge that:

1. You are voluntarily choosing to engage in breathwork facilitated by Endeepenment, and you understand and accept the inherent risks involved.
2. You have disclosed any medical conditions, medications, or mental health concerns that may be relevant, and you agree to tell the facilitator if anything about your health changes before a future session.
3. Breathwork is offered for wellbeing and personal development. It is not medical or psychological treatment, and is not a substitute for advice from a qualified healthcare professional.
4. You may pause or stop the session at any time.
5. Your personal information will be stored securely and treated in strict confidence.

This panel is a summary. Your participation is governed by the full Participation Agreement & Health Declaration at endeepenment.com/participation-agreement — which, among other things, preserves all rights that cannot be excluded by law. Please read it before confirming your agreement below.

I have read and agree to the Participation Agreement & Health Declaration*

Yes, I agreeNo, I do not agree

Do you have any medical conditions we should be made aware of?*

YesNo

Health Information to Discuss

Is there anything else you would like to ask or share?

Where did you hear about Endeepenment?

Prefer to fill in by hand?Print version →