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Somatic Inquiry and Breathwork 1:1
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 somatic therapy and breathwork sessions 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 Services and No Medical Advice

I understand these services are experiential 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, state of awareness, or therapeutic result.

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3. Health Disclosure and Contraindications

I will fully 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 the breath pattern, pacing, or practices to accommodate my needs and safety.

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4. Assumption of Risk and Release of Liability

I understand somatic and breathwork practices can produce strong 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 hereby release and hold harmless 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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5. 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 for emergency care.

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6. Online Session Requirements and Limitations

For online sessions I agree to: participate from a private, safe space free from driving or other hazards; ensure a stable internet connection and appropriate device setup; have a plan for local support if I experience intense reactions; and inform the facilitator of any immediate safety concerns. I understand facilitators cannot physically intervene during online sessions.

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7. Confidentiality and Recordings

I understand that while facilitators will make reasonable efforts to protect privacy, confidentiality cannot be guaranteed in all circumstances. I agree not to record sessions by audio, video, or photographic means without prior written permission from Wildness Healing. I consent / do not consent (circle one) to being photographed, filmed, or recorded by Wildness Healing for educational or promotional use; if I consent, I grant Wildness Healing the right to use such media without compensation.

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8. Cancellation Fees and Refunds

Cancellation policy: full refund or credit with at least 48 hours’ notice; 50% refund or credit for cancellations 24–48 hours before the session; no refund for cancellations under 24 hours or no‑shows. Wildness Healing may charge a processing fee for refunds.

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9. Minors

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

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10. 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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11. 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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