Client Breathwork Waiver
I certify that I am a competent adult of at least 18 years of age or that if I am a minor under the age of 18, I understand that the consent of my parent/legal guardian/person having legal custody will also be required before treatment.
This Informed Consent is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assignees.
I certify that I am in adequate physical, emotional and mental health to participate in a Breathwork session (If not, please specify on the opposite side).
I acknowledge that should this information change, it is my sole responsibility to notify my Breathwork Facilitator.
I consent to and authorise John van Huenen to guide me in a Breathwork Session. This session may include energy healing, vocal toning, tapping, touch work and integration coaching support.
I understand that John van Huenen is not a licensed physician or functional breathing specialist and does not dispense medical advice or prescribe the use of any technique as a form of treatment for any physical or psychological conditions without the advice of a physician - either directly or indirectly.
As a Breathwork Facilitator, John van Huenen offers information of a general nature to help clients in their journey toward greater self-awareness, mind-body connection, emotional, mental, physical, and spiritual well-being and John van Huenen assumes no responsibility for how I (the client) may use this information.
Breathwork journeys are not recommended for people that are pregnant or that have a personal or family history of epilepsy, seizures, cardiovascular problems including angina or heart attacks, high blood pressure, aneurysms, glaucoma, retinal detachment, osteoporosis, or recent physical injuries, surgery or illness - particularly involving the brain, mouth, teeth, nose, throat, thyroid, immune system, lymphatic system, lungs, chest, ribs, spine, neck and/or reproductive organs.
Breathwork is not recommended for people with a personal history of serious mental illness, personality disorders, hospitalization for any psychiatric condition or emotional crisis, suicidality, psychosis, drug or alcohol addiction.
Possible side effects may include dizziness, fainting, changes in body temperature, disorientation, tingling, carpopedal spasms, cramping, emotional breakthroughs, feeling physical, mental, energetic and/or emotional triggering and/or vulnerability.
I understand the nature of the service/session and any questions have been answered to my satisfaction. I understand that the session may involve risks of complications or injury from both known and unknown causes, and I freely assume these risks.
I understand that I have the right to refuse to participate in the session. No guarantee, warranty or assurance has been made to me as to the results that may be obtained.
I certify the above information is correct to the best of my knowledge. I agree to adhere to all safety precautions and regulations during my treatments/sessions. I will not hold John van Huenen or any associated companies or members of their staff responsible for any errors or omissions that I may have made in the completion of this form.