Presented by TSL Services Pty Ltd

Breathwork Interview Form

Living in Truth, Simplicity and Love

one breath at a time

Appointment Details

Date of Appointment: _____________________________________________________________

Time of Appointment: _____________________________________________________________

Full Name: _____________________________________________________________

Please Read carefully before signing

By signing this form, the client indicates a willingness to accept any result of treatment conducted
within or recommended by TSL Services Pty Ltd and their associated practitioners, without holding
TSL Services Pty Ltd and their associated practitioners liable for any circumstances, conditions or
aggravation thereof that those treatments may have influenced or caused. The client also takes full
responsibility for payment of fees within the prescribed time.

Signature: _____________________________________________________________

Date: _____________________________________________________________

PRIVATE AND CONFIDENTIAL

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 Presented by TSL Services Pty Ltd

BREATHWORK INTERVIEW FORM

Biographical Data

Name: _____________________________________________________________

Date of Birth: _____________________________________________________________

Street Address:

Suburb: State:

Country: Postcode:

Email Address:

Home Ph: Work Ph:

Mobile/Cell:

Occupation: _____________________________________________________________

Referred By: _____________________________________________________________

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 Presented by TSL Services Pty Ltd

BREATHWORK INTERVIEW FORM

Birth Information
Where were you born?

 Hospital  Home

 Other, Please Specify:

What time of Year? _____________________________________________________________

Were you a planned Birth?  Yes  No

Were you wanted by both Parents?  Yes  No

If not, why not? _____________________________________________________________

If you have any siblings;

How many are younger? ___________________ How many are older? ________________________

Name of Siblings in order of birth and age gap:

_________________________________________________________________________________

_________________________________________________________________________________

Which Child are you? _____________________________________________________________

(in birth order)

Were there any miscarriages or foetal deaths before you?

 Yes  No

If so, explain: _____________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

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 Presented by TSL Services Pty Ltd

BREATHWORK INTERVIEW FORM

What did your parent/s tell you about your mother’s pregnancy with you?______________________

_________________________________________________________________________________

_________________________________________________________________________________

Were there any complications?  Yes  No

Do you know anything about the labour? ________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Was your birth itself normal?  Yes  No

Please indicate which of the following best describes your circumstances:

 Twin  Premature  On time  Late

Artifical
 Insemination  Fertility drugs  Forceps  Induced
Breech (rear first Face presentation – Turned manually
 Anaesthesia  or footling)  face down  in the utero
Cord around RH Factor blue
 the neck  Placenta Previa  Caesarian baby, Blood
exchange,
 Deformities  Dry Birth  Humidicrib/Incubator  jaundice

Circumcision: If so, what Age? _________________________________________________________

Other Comments _____________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

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 Presented by TSL Services Pty Ltd

BREATHWORK INTERVIEW FORM

Delivered by :

 Male  Female  Doctor  Midwife

Length of time of labour: _____________________________________________________________

Were you separated from your mother at birth?  Yes  No

If so, how long? _____________________________________________________________

Did your mother have any of the following problems at your birth?

 Haemorrhage  Infection  Post Partum Depression  Other, please specify:

_________________________________________________________________________________

Where was your father during your birth?

 In the Delivery Room  In the Hospital  Other, please specify:

Did your parents want a boy or girl?  Boy  Girl

Were you breast fed?  Yes  No

If not, why? _____________________________________________________________

If so, for how long? _____________________________________________________________

If you have any older siblings, how did they feel about your arrival? ___________________________

_________________________________________________________________________________

_________________________________________________________________________________

Other comments about your conception, pregnancy or birth: ________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

PRIVATE AND CONFIDENTIAL

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 Presented by TSL Services Pty Ltd

BREATHWORK INTERVIEW FORM

Childhood

Did you have any illnesses during infancy?  Yes  No

If so, please explain: _____________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Did you have any illnesses during later childhood?  Yes  No

If so, please explain: _____________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Did you have any accidents or injuries as a child?  Yes  No

If so, please explain: _____________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Did you have any major emotional traumas as a child?  Yes  No

If so, please explain: _____________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

PRIVATE AND CONFIDENTIAL

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 Presented by TSL Services Pty Ltd

BREATHWORK INTERVIEW FORM

Have your been either physically or sexually abused?  Yes  No

Please describe the situation or circumstances:____________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Were there any deaths in your family while you were growing up?  Yes  No

If so, who and when? _____________________________________________________________

_________________________________________________________________________________

Did your parents divorce?  Yes  No

If so, what age were you? _____________________________________________________________

How would you describe yourself as a child? ______________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Describe your mother (beginning with what you do not like about her) _________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

What was your relationship to your mother like:

When you were a child _____________________________________________________________

When you were a teenager ___________________________________________________________

Now as an adult _____________________________________________________________

PRIVATE AND CONFIDENTIAL

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 Presented by TSL Services Pty Ltd

BREATHWORK INTERVIEW FORM

Describe your father (beginning with what you do not like about him) _________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

What was your relationship to your father like:

When you were a child _____________________________________________________________

When you were a teenager ___________________________________________________________

Now as an adult _____________________________________________________________

How would you describe your parents relationship with each other while you were growing up? ____

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Are there any other important comments about any other substitute parents, step-parents or people
who took care of you? _____________________________________________________________

_________________________________________________________________________________

Are you now

 Married  Living with someone  Single  Separated

 Widowed  Divorced

Describe your current partner: _________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

What is the state of your relationship? __________________________________________________

_________________________________________________________________________________

Do you have any children? (Age and Sex) _________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

PRIVATE AND CONFIDENTIAL

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 Presented by TSL Services Pty Ltd

BREATHWORK INTERVIEW FORM

FOR FEMALES
How many times have you been pregnant? _______________________________________________

How many deliveries? _____________________________________________________________

Any problem with the births or children?_________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

PRIVATE AND CONFIDENTIAL

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 Presented by TSL Services Pty Ltd

BREATHWORK INTERVIEW FORM

Health

Are you having problems with your body, now or recently?  Yes  No

If so, please describe: _____________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

History of Illness: _____________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Any major tensions, pains or symptoms? _________________________________________________

_________________________________________________________________________________

Are you on any medication? ___________________________________________________________

What for? _____________________________________________________________

Drug use, now and in the past: _________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Are you presently under, or have you recently been under psychiatric care?_____________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

PRIVATE AND CONFIDENTIAL

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 Presented by TSL Services Pty Ltd

BREATHWORK INTERVIEW FORM

Please select any of the following that relate to you:

 High/Low Blood Pressure

Have you recently had Surgery Please specify:

 Diabetes Please specify:

 Allergies Please specify:
 Respiratory Problems Please specify:
 Whiplash

 Epilepsy

 Medication Please specify:

 Recreational Drugs and Frequency of Use:  Alcohol
 Nicotine
 Marijuana
 Other

 Recent Injuries or Accidents Please specify:

 Other Physical, Mental, Emotional or Please specify:
Health Concerns
 Heart Conditions Please specify:
 Pregnant

 Trying for Pregnancy

 Are you currently seeing another allied

health practitioner?
 Were you referred?

PRIVATE AND CONFIDENTIAL

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 Presented by TSL Services Pty Ltd

BREATHWORK INTERVIEW FORM

Personal Insight
Please list the personal development seminars or trainings you have completed? ________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

What are your major fears? ___________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

What is your most negative thought about yourself? _______________________________________

_________________________________________________________________________________

What is your most negative thought about life? ___________________________________________

_________________________________________________________________________________

What is your relationship to:

Sex
Money
Women
Emotions
Love
Your Body
Men
Work
Your Health

What is your most negative thought about relationships? ___________________________________

What religion were you brought up in? __________________________________________________

What is your concept of God? _________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

PRIVATE AND CONFIDENTIAL

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 Presented by TSL Services Pty Ltd

BREATHWORK INTERVIEW FORM

What is your most positive quality? _____________________________________________________

_________________________________________________________________________________

If you could be, do and have anything in the world, what would you be, do and have? No limitations!

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

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PRIVATE AND CONFIDENTIAL

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 Presented by TSL Services Pty Ltd

BREATHWORK INTERVIEW FORM

Breathwork Session
Do you have any negative thoughts about breathing?_______________________________________

What have you heard about Rebirthing or Breathwork? _____________________________________

_________________________________________________________________________________

_________________________________________________________________________________

What questions do you have about Rebirthing or Breathwork? _______________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

What is your understanding of the concept that “Thought is Creative”? ________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

What outcome do you wish to achieve as a result of this session? _____________________________

_________________________________________________________________________________

Are you clear about the price and the number of sessions etc? _______________________________

Do you have anything to clear with me, your breathworker? _________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Other comments: _____________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

PRIVATE AND CONFIDENTIAL

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