This form supports your safety and wellbeing during breathwork, movement, and nervous system practices. Please read carefully and answer honestly.

Purpose of This Disclosure

movewithME practices are gentle and supportive, but they may involve breathwork, mindful movement, and nervous system activation. This form helps ensure the practices offered are safe and appropriate for you.

Health Information

Please disclose any relevant conditions, including:
• respiratory conditions
• cardiovascular concerns
• recent injuries or surgeries
• pregnancy
• mental health considerations
• dizziness, fainting, or seizures
• any condition that may affect your participation

This information is confidential and used only to support your safety.

Your Responsibility

By participating, you agree to:
• listen to your body
• move at your own pace
• stop if you feel discomfort, pain, or overwhelm
• inform the facilitator of any changes to your health
• seek medical advice if you are unsure about participating

movewithME practices are not a replacement for medical or therapeutic care.

Facilitator Responsibility

movewithME will provide:
• trauma aware guidance
• culturally respectful practices
• options and modifications
• a supportive environment
• clear communication around safety

Acknowledgement and Agreement

By signing below, you confirm that the information you have provided is accurate to the best of your knowledge, and that you understand your responsibilities during participation.

Name: __________________________

Date: __________________________

Signature: ______________________