New Client Intake Questionnaire

Your name *

Email *

1.What brings you here?

What made you interested in breathwork right now?

What would you most like support with? Select any that apply.

If this work felt helpful, what would be different in your daily life?

Is there anything important you want me to understand about your current situation?

2.Your day-to-day rhythm

3.Stress and nervous system patterns

On a typical day, how would you rate your stress from 0 to 10?

What tends to trigger or add to your stress?

How does stress show up for you physically, mentally, or emotionally?

What do you usually do when you notice stress building?

Are there situations where you feel shut down, numb, disconnected, panicky, or overwhelmed? If so, what helps you feel more settled?

What already helps you feel grounded, calm, clear, or restored?

4.Sleep and recovery

How would you describe your sleep lately?

What time do you usually go to bed and wake up?

Is falling asleep, staying asleep, waking early, or waking rested the biggest challenge right now?

What tends to happen in the hour before bed?

Do you use caffeine, alcohol, nicotine, cannabis, sleep aids, or supplements that may affect your sleep? Share only what feels relevant.

What would better sleep look like for you?

5.Learning and guidance preferences

6.Practice preferences and access

Have you tried breathwork, meditation, yoga nidra, mindfulness, or somatic practices before? What felt useful or unhelpful?

Are there any breathing techniques, sounds, music, language, or approaches you do not enjoy?

Would you prefer practices with music, without music, or both?

With musicWithout musicBoth

Where are you most likely to practice?

What might get in the way of keeping a practice going?

What would make it easier to return to the practice on a difficult day?

7.Health and safety

Do you have any physical or mental health conditions, current injuries, medications, or recent life events that you think I should know about before we begin?

Have you ever experienced dizziness, fainting, panic, dissociation, strong emotional activation, or discomfort during breathing or meditation practices?

Are you currently working with a physician, therapist, or other healthcare professional? If yes, is there anything relevant to coordinate around?

Is there anything that would help you feel safer, more comfortable, or more in control during a session?

8.Closing

What would make this experience feel genuinely worthwhile to you?

Is there anything else you would like to share before we begin?

What is the best way for me to support your follow-through between sessions?