Private Mentoring Questionnaire

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Private Sessions Questionnaire

Private Mentoring in Restorative Breathwork® with Kathleen Barratt

Name

Phone Number

How did you hear about this course?

City

State

Country

How did you hear about Kathleen Barratt and Restorative Breathwork?

Briefly describe your personal interests and goals for participating in this program.

Do you have previous experience with other systems of breathwork? If so, please describe the style of practice(s) or areas of study. Examples include styles (e.g., pranayama, Holotropic Breathwork™), receiving breathwork from a facilitator, and theoretical (non-experiential) studies.

What other systems have you studied or currently study that foster physical, mental and spiritual health? Examples: Yoga, Meditation, Tai Chi, Contemplative Sciences, Energy Medicine, etc.

Do you have a meditation practice? If yes, briefly describe how long you have been practicing, level of consistently, system of meditation, etc.

Briefy describe the stressors in your life: Work / Personal / Other

Do you have any chronic pain, physical limitations, or disabilities? If yes, briefly describe.

Have you had a serious illness or major surgery within the last five years? If yes, briefly describe.

Have you experienced trauma, either physical or emotional, recently or in the past? Briefly Describe

Do you currently have or have you had any of the following conditions in your lifetime?

Respiratory conditions

Heart disease or other cardiovascular problem

High Blood Pressure

Seizures or strokes

Hypertension

Detached Retina

Glaucoma

Epilepsy

Diabetes

Diagnosed mental-health conditions

Anxiety or panic attacks

Severe migraine headaches

What wellness professionals have you used or currently use? Examples: Coach, Acupuncturist, Psychologist, Chiropractor, Homeopath, Nutritionist, etc.

12 Private sessions over 3-6 months,
our premium program

Work directly with
Kathleen Barratt

For those seeking a personalized approach to attaining breath mastery

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Private Mentoring with Kathleen Barratt