Jenise Russo
B R E A T H W O R K

Jenise Russo
jenise@jeniserusso.com
June 10th, 2024

Introduction
Breathwork is a practice involving specific breathing techniques designed to enhance physical, emotional, and spiritual well-being. It can bring about profound changes and is considered safe for most individuals. However, like any therapeutic practice, it carries potential risks and benefits. This informed consent form outlines the nature of breathwork, its potential effects, and your rights and responsibilities as a participant.

Purpose of Breathwork
Breathwork aims to improve emotional and physical health through controlled breathing exercises. Benefits may include reduced stress and anxiety, improved mental clarity and focus, enhanced emotional release and processing, increased energy and vitality, and spiritual growth and self-awareness.

Potential Risks
While breathwork is generally safe, potential risks include dizziness or lightheadedness, hyperventilation, emotional discomfort or distress, and physical discomfort.

Contraindications
Breathwork may not be suitable for individuals with certain medical conditions. You should not participate if you have severe asthma or respiratory issues, cardiovascular disease or severe hypertension, epilepsy or seizure disorders, recent surgeries or injuries, or severe mental health conditions.

Participant Responsibilities
As a participant, you agree to inform the practitioner of any medical conditions or concerns, follow the practitioner's instructions carefully, communicate any discomfort or distress immediately, and abstain from alcohol or recreational drugs prior to sessions.

Practitioner Responsibilities
The practitioner agrees to provide a safe and supportive environment, offer clear instructions and guidance, respect your confidentiality and privacy, and respond to any concerns or discomfort during the session.

Confidentiality
All information shared during breathwork sessions will remain confidential unless you provide written consent to share information, disclosure is required by law, or there is an imminent risk of harm to yourself or others.

Consent
By signing this form, you acknowledge that you have read and understood the information provided, you have had the opportunity to ask questions and receive answers, and you voluntarily consent to participate in breathwork sessions.

Participant Name: ___________________________________
Participant Signature: ________________________________
Date: _____________________________________________
 
Emergency Contact Information
Name: _____________________________________________
Relationship: ________________________________________
Phone Number: _____________________________________

Acknowledgment
I acknowledge that I have read and understood the above information and consent to participate in breathwork sessions. I understand that I may withdraw my consent at any time.
Participant Signature: ________________________________
Date: _____________________________________________

If you have any questions or concerns, please feel free to contact me, Jenise Russo, at jenise@jeniserusso.com or 973-870-1030.