Breathwork Participation Agreement, Informed Consent and Release.

Please read this entire agreement carefully before completing the form below.

Nature of the Experience

I acknowledge that somatic breathwork is a deep and powerful process. I have notified the practitioners of any physical injuries, mental or psychological conditions I have. I engage in this experience willingly and take full responsibility for my own physical, mental, and emotional experiences during and after the session.

Contraindications

Somatic breathwork is intended as a personal growth experience and should not be looked upon as a substitute for psychotherapy. It is not appropriate for pregnant women, for persons with cardiovascular problems, including angina or heart attack, high blood pressure, glaucoma, retinal detachment, osteoporosis, history of seizures, stroke, major psychiatric conditions, recent surgery, acute infectious illness, or epilepsy. If you have any doubt about whether you should participate, please consult with your primary care physician. Persons with asthma should bring their inhaler and consult with their primary care physician.

Release

I hereby release and hold harmless Gabrielle Wallace, (Wilde Soma) from any and all results that arise during or from the Somatic Release Breathwork. I waive all rights under law regarding the same. I or my representative(s) agree to full release and hold Gabrielle Wallace and Wilde Soma harmless from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).

Attestation of good health

I hereby confirm that I have read and understood the above information and attest that my general health is good to participate.

Confirmation and Electronic Agreement

By completing and submitting the form below, I confirm that:

  • I am at least 18 years old.

  • I have read and understood this entire agreement.

  • I have had the opportunity to ask questions before participating.

  • I have answered the health-screening questions honestly and completely.

  • I understand the nature of the breathwork experience and its potential risks.

  • I voluntarily consent to participate.

  • I understand that typing my full legal name and submitting this form constitutes my electronic acknowledgment and agreement.

  • All information below - Name, Email, Phone Number are confidential and for safety record only.