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Breathwork Circle
Intake Form & Waiver

Please fill out the following form prior to your appointment
Client Consent and Agreement

1. Acknowledgement of Voluntary Participation

I acknowledge that I voluntarily choose to participate in a breathwork circle offered by Wildness Healing, delivered in person or online. My participation indicates that I have read, understand, and agree to this Waiver and Release.

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2. Nature of Group Work and No Medical Advice

I understand breathwork circles are experiential group practices intended to support wellbeing and are not a substitute for medical, psychiatric, or psychological care. They do not constitute medical advice, diagnosis, or treatment. Wildness Healing does not guarantee any particular outcome or state of awareness.

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3. Health Disclosure and Contraindications

I will disclose any relevant medical or mental health conditions, medications, pregnancy status, or other factors that could affect my participation. Common contraindications include but are not limited to: cardiovascular disease, uncontrolled high blood pressure, recent surgery, glaucoma or retinal detachment, epilepsy or seizure disorders, psychosis, bipolar disorder, active suicidal ideation, and pregnancy. Disclosure of a contraindication does not automatically exclude me from participating; the facilitator may adapt breath patterns, provide alternative practices, or recommend I sit out parts of the circle to ensure safety.

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4. Group Dynamics, Confidentiality, and Personal Sharing

I understand that in a group setting I may hear or share personal information. While facilitators will encourage confidentiality, Wildness Healing cannot guarantee confidentiality among participants. I agree to respect others’ privacy and not to disclose identifying personal information shared in the circle.

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5. Assumption of Risk and Release of Liability

I understand breathwork can produce intense physical, emotional, or psychological responses. I assume full responsibility for all risks, known and unknown, associated with my participation, including physical injury, emotional distress, or other harm. I release Wildness Healing, its facilitators, contractors, volunteers, and affiliates from any and all claims, liabilities, losses, or damages arising from my participation.

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6. Recording and Media Consent

Recording, Photography, and Media Consent I will notify Wildness Healing in writing if I do not consent to being photographed, filmed, or recorded. If I do not provide written notice, I understand that Wildness Healing may photograph, film, or record sessions and may use such media for educational and promotional purposes without compensation. I will not personally record sessions by audio, video, or photographic means without prior written permission from Wildness Healing and all affected participants.

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7. Online Circle Requirements and Limitations

For online circles I agree to: participate from a private, safe space; ensure a stable internet connection and device setup; use headphones if requested; and have a plan for local support if I experience intense reactions. I understand facilitators cannot physically intervene during online circles.

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8. Illness and Safety Protocols

I will not attend in‑person circles if I am experiencing symptoms of contagious illness and will follow any health and safety protocols Wildness Healing provides. I will bring water, a mat or blanket, and any personal items needed for comfort.

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9. Fees, Transfers, and Refunds

Breathwork circle policy: ticket transfers permitted up to 24 hours before the event; full refund or credit with at least 48 hours’ notice; 50% refund or credit for cancellations 24–48 hours before the event; no refund for cancellations under 24 hours or no‑shows.

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10. Emergency Contact and Medical Authorization

In the event of a medical emergency, I authorize Wildness Healing facilitators to reach out to my emergency contact and to seek emergency medical care on my behalf if necessary. I understand I am responsible for any costs incurred.

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11. Minors

Participants under 18 require a parent or legal guardian signature and must be accompanied by a guardian for in‑person circles unless otherwise agreed in writing. Contact Wildness Healing directly.

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12. Governing Law and Severability

This Agreement is governed by the laws of British Columbia, Canada. If any provision is found invalid, the remaining provisions remain in effect.

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13. Acknowledgement and Signature

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Thanks for submitting!

Lou Piché
Traditional Thai Massage
Holistic Health & Nutrition Consultation

wildnesshealing@gmail.com | 778.348.7348 | www.wildnesshealing.com

778.348.7348    |   wildnesshealing@gmail.com

 

1822 S. Island Highway, Campbell River

 

Open Hours

Monday to Friday 9:00am to 6:00pm 

Saturday if requested

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​We respectfully acknowledge the unceded traditional territory of the LigwiÅ‚da’xw people; the We Wai Kai, Wei Wai Kum, Kwiakah First Nations, and the traditional keepers of their land.  We want to say thank you for allowing us to live, work, and play on your lands.

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