Your name:

Your Birthdate:

Your email

Your phone

Your preferred method of contact:
PhoneEmailText

Emergency Contact Name & Phone:

 
Health & Wellness History
 
Do you have any current medical/mental health conditions or diagnoses?
YESNO

Are you currently taking any medications/supplements/substances that may affect you mentally or emotionally?
YESNO

Have you experienced any of the following? (Check all that apply):
Asthma or breathing difficultiesHigh or low blood pressureHeart conditionsEpilepsy or seizuresMental health diagnosis (e.g., PTSD, anxiety, depression)Recent surgery or injuryPregnancy (current or recent)NONE

Do you have a history of significant trauma?
YESNO
If YES, please briefly describe (optional)

 
Breathwork & EFT Experience
 

Have you ever participated in:
Breathwork: YESNO

Have you ever participated in:
EFT/Tapping: YESNO

What is your primary reason for seeking sessions? (Select all that apply)
Stress reductionTrauma releaseEmotional regulationPhysical healingPersonal growth/spiritual connectionOther

What outcomes are you hoping to achieve?

 
Consent & Acknowledgment
Please read and check to confirm each of the following:
 

I understand that breathwork and EFT/Tapping are complementary practices and not substitutes for medical or psychological treatment.I take full responsibility for my physical and emotional well-being during and after sessions.I agree to communicate honestly and openly with the practitioner and honor my own limits.I acknowledge that strong emotions may arise during sessions, and I am prepared to handle them in a safe container.I consent to receive services from the practitioner listed and understand I can stop the session at any time.If I have a private session with Marianna Giokas, I allow Marianna Giokas to record my name, summary case information and date of visit as one of her clients. I understand that my name and personal information will never be disclosed or made public.I understand that there is a 24-hour cancellation policy for any sessions I sign up for in order for me to receive a refund or credit. I also understand that there is a 30-day refund period for any sessions purchased.I agree to assume full responsibility for my own physical, emotional and mental health and hold harmless Marianna Giokas, Zen Den Wellness, and/or the Zen Den LLC from any physical, emotional and/or mental damage that may be attributed to the energy modalities mentioned above.