Date of birth
What aspects of yourself, your life would you like to change?? What happiness means to you? Are you there? If not, what’s stopping you from being in this state? Anything else you'd like me to know?
What is your goal? How would you like to feel ?
Please list any conditions or symptoms you are currently experiencing (physical, mental or emotional).
Are you pregnant ??
Birth information and position in family. What do you know about your birth? Were there any complications?
Other complementary therapies currently used. If yes, how often?
Is anyone in your family needs a therapy, your partner, kids? Tell me more about your relation with your mother (no matter if the parent isn’t alive). Relation with your father (no matter if the parent isn’t still alive). Try to include as many details as you can. How they are to each other in the past and now.
What frequency of the visit do you prefer?
Once per week
Twice per week
Once per month
Is there anything else you would like me to know about you?
I give permission to Justyna Kubach to perform the role of my Facilitator in Breathing sessions. I understand that if I have medical concerns it remains my responsibility to consult a medical professional and inform the Facilitator. I understand that my Facilitator makes no claim to benefit any specific condition and gives no guarantee as to outcome. I, intending to be legally bound, hereby agree and release from liability and indemnify and hold harmless, the Facilitator. I agree to accept financial responsibility for any costs or damages which might arise from participation in breathing activities. I agree to terms & conditions.
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