Pilates and Breathwork Intake Form - Erica Breen Wellness

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Personal Information

Name(Required)

First Last

Email(Required)

Birthday

MM slash DD slash YYYY

City / Country

Emergency Contact

Name

Relationship

Phone

Health & Movement Background

Injuries / Medical Conditions

Current pain, symptoms, or limitations

Experience with Pilates, movement, or breathwork

Props or equipment available

What are you hoping to rebuild, return to, or feel differently in your body?

What feels most important for you right now in your health or movement practice?

Health

I confirm that:

I am physically and mentally able to participate in movement and breathwork sessions

I have consulted a licensed healthcare provider where appropriate

I will inform Erica Breen Wellness of any changes to my health status

Informed Consent & Assumption of Risk

I understand that participation in Pilates, breathwork, and wellness sessions may involve physical movement, breath techniques, and nervous system practices that carry inherent risks, including but not limited to: • Injury • Dizziness or lightheadedness • Emotional responses • Nervous system activation • Symptom flare-ups

(Required)

I voluntarily choose to participate and assume full responsibility for all risks, known or unknown.

Virtual Session Responsibility

I understand that all sessions are conducted virtually without in-person supervision.

I accept full responsibility for:(Required)

My physical environment

Safe use of any equipment

My body, movement, and participation during sessions

Medical Disclaimer

I understand that Erica Breen does not diagnose, treat, or provide medical advice. These sessions are educational and supportive in nature and are not a substitute for medical, psychological, or psychiatric care.(Required)

I understand the Medical Disclaimer

Privacy & Communication Acknowledgment

I understand that communication may occur via email or virtual platforms, which are not fully secure. I acknowledge that these services are not subject to medical confidentiality laws, including the Health Insurance Portability and Accountability Act (HIPAA), and I accept any associated risks. I agree to use discretion when sharing sensitive personal or medical information.(Required)

I acknowledge the Privacy & Communication terms

Release of Liability

I knowingly and voluntarily release and hold harmless Erica Breen Wellness from any and all liability, claims, or demands arising from my participation, including those arising from negligence.(Required)

I agree to the Release of Liability terms

Indemnification

I agree to indemnify and hold harmless Erica Breen Wellness from any claims, damages, or expenses resulting from my participation.(Required)

I agree to the Indemnification terms

No Guarantee of Results

I understand that outcomes vary based on individual circumstances, history, and participation, and no specific results are guaranteed.(Required)

I agree

Policies

• Sessions begin and end at scheduled times
• Late arrivals do not extend session time
• 24-hour cancellation required. Email ericabreenwellness@gmail.com or cancel in Google Meet invitation.
• Late cancellations or no-shows = full charge
• Payment due 24 hours in advance or session will be canceled
• All packages and sessions expire 6 months from purchase
• No refunds will be given

(Required)

I have read and agree to the Policies

Consent

(Required)

I have read, understood, and agree to the above information, policies, disclaimers, and liability terms. I acknowledge that I am responsible for my decisions and participation.

Your Signature(Required)

Date

MM slash DD slash YYYY