INTEGRATIVE INTUITION CLIENT QUESTIONNAIRE& LIABILITY WAIVERS PARTICIPANT INFO I am attending... * Private 1-on-1 Breathwork/Coaching session with Erica Breathwork through my Employer Shadow Types Seminar/Coaching through my company In-person Workshop Virtual Workshop Name * First Name Last Name Date of Birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Do you consent to receive Text message reminders and updates about your upcoming session? * Yes No BACKGROUND My parents are/were... * Unmarried Partnered Married Divorced Widowed Please check dynamics you were exposed to/experienced before the age of 19. * Adopted (self) Adopted (siblings) Traumatic Birth Alcohol/Substance Abuse Physical Abuse Sexual Abuse Spiritual Abuse Suicide Chronic Illness/Disease Parental Gaslighting Death of Parent or Sibling Absentee Parent Narcissistic Parent Mental Illness in Parent None of the Above I am... * Single Married Separated Divorced Widowed For those currently in a romantic relationship, how long have you been with your partner? * On a scale from 1-10 (10 being great), how would you rate the quality of your relationship? If you're single, select "0" * 0 (single) 1 2 3 4 5 6 7 8 9 10 Do you have children? If so, please list ages below. If not, input "N/A" * Occupation * Religious Affiliation/Spiritual Preference * PHYSICAL HEALTH How would you rate your physical health at the present time? * Poor Unsatisfactory Satisfactory Good What are your most pressing physiological concerns right now (pain, disease, injury, etc.)? If nothing applies, input "N/A" * Do you have any of the following conditions that have either been diagnosed and/or require medication? * Cardiovascular Disease Angina Heart Attack High Blood Pressure Retinal Detachment Osteoporosis Recent injury or surgery Any condition for which you take regular medications History of panic attacks, psychosis, or disturbances Severe Mental Illness Seizure Disorders Family history of Aneurisms Asthma COPD None of the Above If you checked any of the above, please explain (dates, treatment, current condition, etc.). If none apply, input "N/A" * Please provide your current prescription and OTC medications/supplements and their dosages. If none, input "N/A" * Are you experiencing any of the following in regards to your sleep habits? * Sleep too much Sleep too little Poor quality Insomnia Disturbing dreams N/A Which of the following changes or difficulties are you experiencing with regard to your eating habits? * Eating less Eating more Binge eating Restrictive eating N/A MENTAL/EMOTIONAL HEALTH Are you currently receiving psychological services, professional counseling, psychiatric services, or any other mental/emotional health services? * Yes No Please provide a brief overview of different mental/emotional/spiritual growth work modalities you've tried in the past. Do you feel they were effective? Why/Why not? * If known, please provide your predominant Shadow Type Personality Trait or Enneagram Numbers. Input "Unknown" if you're unsure. * What sorts of things tend to trigger you? How do you normally cope/respond? * What do want more/less of in your life right now? Tell me about your goals/intentions/motivations related to your wants. * What sorts of "blocks" are you experiencing that are holding you back/preventing you from receiving what you want? * Is there anything else you would like for me to know? * LIMITED LIABILITY WAIVER SERVICES & DISCLOSURE * I, the participant, (“Releasor/Participant”), understand that in participating in consultations, coaching sessions, breathwork sessions, (collectively referred to as “experiences”) offered by Erica McNally of Integrative Intuition (“Releasees/Facilitator”), I agree to the following: I understand that breathwork and experiences offered by Releasees are designed to enhance quality of life and support holistic wellbeing and are not intended to constitute medical advice or any substitution for medical care. I understand that experiences are not intended to be relied upon for diagnosis or treatment in relation to any health problem, and services of the Facilitator do not replace the care of licensed medical professionals. I CONSENT and AGREE MEDICAL DISCLAIMER & CONTRAINDICATIONS * I understand that breathwork and experiences may involve strong connected breathing, which can result in dramatic experiences accompanied by strong emotional and physical responses. I understand that I may find the Activities physically, emotionally, or mentally stressful, and that breathwork and experiences are not safe under certain medical conditions and not advised for persons with a history of cardiovascular disease or prior heart attack, high blood pressure, use of prescription blood thinners such as Coumadin, epilepsy or seizures, glaucoma, osteoporosis, severe asthma, bipolar disorder, schizophrenia, dissociative disorders, history of significant trauma, and during pregnancy. I hereby state that I am not pregnant, and if any of the above conditions apply to me, I will advise the Facilitator prior to participation. I understand I am fully responsible for seeking medical help to treat all symptoms that are present before and after the experiences. I hereby state that I am physically and mentally fit to participate in experiences and understand that it is solely my responsibility to seek professional support after experiences if I feel unstable mentally or emotionally. I knowingly waive any claim I may have against the releases for injury or damages that I may sustain as a result of participating in experiences. I CONSENT and AGREE RISKS * I understand and acknowledge that the experiences in which I am participating in bear certain known inherent risks that contribute to the unique character of these experiences, and that Facilitator cannot eliminate, alter, or control these inherent risks. “Risks” include, but are not limited to, known and unknown health conditions, inaccessibility to immediate medical attention, risks inherent in breathwork that include, but are not limited to, over-exertion, psychological distress and disorientation, hyperventilation, respiratory alkalosis, muscle spasms, chest pain, numbness, heart attack, death, and injury or death caused by negligence on the part of Participant or other people around Participant. I hereby expressly and specifically assume the risk of injury or harm, and agree that my involvement in experiences is purely voluntary, and that I elect to participate in spite of the risks. I CONSENT and AGREE CONFIDENTIALITY * I understand that information shared with the Facilitator is privileged communication and strong ethical standards of confidentiality are maintained. I understand that in voluntarily revealing personal information in group experiences, rights of privacy and confidentiality are waived and cannot be guaranteed. I also understand that confidentiality may be waived, without consent, if there is imminent danger to yourself or others, or there is occurrence of child, elder, or dependent adult abuse or neglect. I CONSENT and AGREE METHODOLOGY, WARRANTIES, & OUTCOMES * I agree to be open minded to Facilitator’s methods and partake in Activities and services as proposed and instructed. I understand that Facilitator has made no guarantees as to the outcome of experiences, and that information and testimonials presented before, during, or after experiences do not constitute a warranty of specific outcomes. I CONSENT and AGREE LIMITATION OF LIABILITY * By using Integrative Intuition services and purchasing experiences, I accept any and all risks, foreseeable or non-foreseeable, arising from such transaction. I agree that both the Facilitator any physical site Owners will not be held liable for any damages of any kind resulting or arising from including but not limited to; direct, indirect, incidental, special, negligent, consequential, or exemplary damages happening from participation in experiences or use of materials provided. I CONSENT and AGREE
