Breathwork Journey Waiver Form: Learn more about the Soul Journey Breathwork

Soul Journey Breathwork

CONTRAINDICATIONS & LIABILITY WAIVER FORM

As we prepare to deepen in,

I have compiled some information and details of how our professional relationship will unfold to help bring as much clarity, understanding, and ease to you, your journey, and your system.

Please read and sign this form. Let me know if you have any questions or concerns.

Signing the Informed Consent Form includes agreement to the terms of this document.

I acknowledge that Deanna Jannuzzi Banaszak is a Priestess, Coach and Consultant, Sound and Breathwork Facilitator, Somatic Practitioner, and Yoga Instructor. The purpose of our session together is to provide mental, emotional, and spiritual support using active Breathwork, Sound, and any other tool within Deanna’s scope of practice that feels appropriate based on the needs of the session.

I acknowledge that I am entering this relationship as a sovereign individual, and will acknowledge my needs, limitations, and abilities, and understand that my voice is fully welcome and encouraged. I agree to utilize my voice through open communication to enhance a mutual understanding of what is going on for me, what my needs are, and to help Deanna Jannuzzi Banaszak best support me in my journey. I also understand that consent is mine to give and withdraw at any time, and will honor my needs first and foremost.

I understand that Breathwork and the services offered in this container are complementary healing modalities that in no way substitutes for medical interventions, body therapy, or psychotherapy. I also understand that Deanna Jannuzzi Banaszak may make suggestions within her scope of practice for self-care as well as appropriate referrals if needed.

I also acknowledge that Deanna Jannuzzi Banaszak is not a medical doctor or mental health care professional, and accordingly cannot and will not provide me with medical advice or psychological advice. I understand it is my responsibility to have resources available beyond the scope of work and will rely on my own medical practitioner or mental health professional for advice for medical or psychological advice. I will rely on Deanna Jannuzzi Banaszak only for the sharing of important skills and tools involved in increasing my mental, emotional, physical, and spiritual awareness through the scope of our work together.

I recognize that Breathwork and Alchemical sessions with Deanna are only one tool in the upkeep and care of my wellbeing. I also recognize that I am a freely consenting adult and that it is up to me as to whether I work with Deanna Jannuzzi Banaszak and engage with her offerings. I understand that it is advisable to consult with my medical or mental health professional prior to doing so.

Soul Journey Breath Contraindications

While the Soul Journeywork that this particular breathwork can evoke is generally considered safe, it is not uncommon to experience deep psychic explorations, varied brainwave states, body movements, muscle clenching/releasing, emotional and spiritual experiences, and possible surfacing of emotional trauma and triggers.

Safety is of the utmost importance. It is vital that you read through the contraindications for the Soul Journey Breathwork and inform Deanna Jannuzzi Banaszak of any and all medical conditions and medications that you are currently being treated with/for or have taken in the past 3 months. This information will be held in strict confidence.

The following conditions are contraindications of this particular Breath and
I agree to inform Deanna of any/all that I have experienced prior to the breath session:

Cardiovascular Disease (including angina or any history of heart attacks or heart weakness)
High Blood Pressure
Glaucoma
Retinal Detachment
Osteoporosis
Significant recent physical injuries or surgeries
Significant recent emotional/spiritual trauma
Asthmatic (requiring use of an inhaler)
Pregnancy (esp during 1st trimester)
Contagious Illness
Seizures, Epilepsy
Traumatic Brain Injury
Diagnosis of Bipolar disorder, schizophrenia, or previous psychiatric
condition requiring medical intervention.
Medications that indicate significant mental health imbalance
Not being of sound and balanced mental faculties (dementia, under the
age of 18, recent trauma state, etc)

I also agree to consult with my physician, therapist, and any other medical professional I am working with to confirm that this practice is safe for me to engage with.

Write out a list of all medical information, medications, and notes to share with Deanna

I understand that all the information given to Deanna Jannuzzi Banaszak is guarded in strict confidentiality at all times. I also acknowledge that Deanna works with mentors, and for the purposes of continued learning, safety, and refinement, broad information about my case may be reviewed, with absolutely no identifying information disclosed at any time.

Yes, I agree

I am participating in a service during which I will receive information and instruction about Breathwork movements and meditation. I represent and warrant that I have no physical or mental health condition that would prevent my safe participation in Breathwork sessions, that I will or have provided Deanna Jannuzzi Banaszak with my medical history and information, and that I have seen and read the Breathwork contraindications document.

Yes, I agree

I certify that I do not have any injuries, illnesses, diseases, and/or health concerns including and not limited to physical, mental, emotional, and/or spiritual health that would prevent me from participating in this session. If I have any question about this, I know that it is my responsibility to consult with a licensed medical practitioner prior to the session. I will seek professional help if needed.

Yes, I agree

I will advise Deanna Jannuzzi Banaszak of any mental or physical health conditions, medications, concerns, and dietary requirements upon signing of this agreement. If I have health conditions, dietary requirements, or am taking any medications that may be affected by the Breathwork session, I know that Deanna Jannuzzi Banaszak reserves the right to refuse the Breathwork session.

Yes, I consent.

I know that this Breathwork journey may involve deep psychic explorations, subconscious revelations, body movement, and energy movement that may push my edges at moments. I will remain self-responsible to know my limits and not exceed them. If Deanna invites something that may push me beyond my limits, I will remain self-responsible to listen to my own body’s wisdom and guidance and stop or modify the practice suggestions. I am in control of my own body and I can always “stop” at any time.

Yes, I consent.

Deanna Jannuzzi Banaszak is not liable for any medical or psychiatric conditions, which may develop or worsen during or subsequent to the Breathwork session. I also acknowledge that it is not the responsibility of Deanna Jannuzzi Banaszak to advise me in regards to my health or well-being. I understand and agree that I am fully responsible for my own self-care & well-being. I affirm that I am of sound mental health to make such an agreement. I know that I can choose to withdraw from this experience at any time without judgment.

Yes, I consent.

Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Deanna Jannuzzi Banaszak from and against any and all claims or liability of whatsoever kind of nature arising out of or in connection with my session(s).

Yes, I consent.

I know that this is a sacred space of deep energetic transmission. I know there is a possibility of triggering intense emotions, memories, and experiences. If I am feeling triggered, I know that it is safe to consciously bring it to the attention of Deanna Jannuzzi Banaszak and I will remain in responsibility for my own being. I am aware that I am responsible to uphold the agreements within this waiver. If Deanna Jannuzzi Banaszak feels that I have violated the agreements or that I have not disclosed information truthfully on my informed consent form or waiver, she has the right to deny or stop the session at any time.

Yes, I consent.

I have read this Consent Form prior to signing and I understand this release shall be effective and binding upon my heirs, next of kin, executors, administrators and assigns and release and waive all claims for damage howsoever incurred or to be incurred, as a result of such services, information and support. I am aware that by signing this Consent Form I am waiving certain legal rights, which I or my heirs, next of kin, executors, administrators and assigns may otherwise have had against Deanna Jannuzzi Banaszak and the work I do with Deanna (including but not limited to breathwork, coaching, sound, somatic practices, group, and one on one sessions).

Yes, I agree

Signature

This agreement is being signed voluntarily and not under duress of any kind.

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