intake form | Being Lumen

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being lumen intake form

all new clients are required to complete the being lumen intake form.

First Name

Gender

Email Address

Last Name

Date of Birth

Phone Number

Please check if you permit us to contact you via WhatsApp for notification, updates and announcements.

Enter your Address

Current Status

Salary Bracket (Optional)

Company name and Position

Do you feel addicted to social media/screens?

Please indicate your level of experience in breathwork

Please indicate your level of experience in meditation:

Do you have any current medical conditions or concerns that you would like to disclose? Please provide details below

Please indicate your level of experience in toning (nada yoga/sound healing):

All personal medical information disclosed is held in strict confidence and will be used solely to provide you with appropriate services and care.

Which areas are you looking to address through our holotropic breathwork service? (Please select all that apply): * Required

Manage stress and anxiety

Overcoming social anxiety

Coping with performance anxiety

Managing panic attacks

Improve emotional well-being

Releasing stuck emotions

Processing trauma

Enhance mental clarity and focus

Increasing creativity and self-awareness

Enhancing mindfulness and presence

Improve physical and mental health

Coping with addiction or dependency

Enhancing sleep quality and physical vitality

Boost self-esteem and self-worth

Releasing limiting beliefs

Cultivating forgiveness and inner peace

Navigate life transitions

Coping with major life changes

Managing work or career stress

Spiritual growth and discovery

Understanding past life experiences

Deepening a sense of purpose and alignment

Promote relaxation and resilience

Building adaptability and resilience

Seeking relaxation and peace

Addiction to scrolling

How did you hear about us?

I hereby confirm that I have fully read and understand the liability and release waver received in my welcome email.

Please sign your name to confirm you have fully read and understand the liability and release waver received in your welcome email.

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