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**WAIVER AND RELEASE OF LIABILITY FOR EMOTIONAL RELEASE AND BREATHWORK SESSION**


This Waiver and Release of Liability (the "Agreement") is entered into on today’s date by and between Terah Pack and any facilitators participating in today’s session and client signing this waiver and SoulutionCo 

Virtual & Live Experience

The Client understands that the Emotional Release and Breathwork Session (the "Session") is a holistic and therapeutic practice designed to facilitate emotional release, relaxation, and personal growth. The Client acknowledges that the Session may involve physical and emotional movements, breathing exercises, and guided meditation.

"Breathwork" encompasses a range of breathing exercises designed to enhance physical, spiritual, and emotional health. It is used to promote healing, health, and self-awareness and is thought to help those suffering from chronic pain, anxiety, PTSD, grief, and depression.


The effects of breathwork may include all types of physical and emotional release, including but not limited to muscle contractions, sweating, nervous system and biochemical changes, heightened sensory awareness, headache, fainting, crying, dizziness, and other symptoms.


Although these effects may be expected, especially during a heavy or extended breathwork activity, be advised that there is no way to eliminate the risks or to anticipate the length of any physical or emotional effects (which may last beyond the breathwork itself). Although breathwork is used for healing purposes, in some cases people have experienced adverse effects, and as a result, breathwork is contraindicated (not recommended) for those with a personal or family history of cardiovascular disease, myocarditis, heart attack, high blood pressure, glaucoma, retinal detachment, bone or muscular disorders, significant physical injuries, or recent surgery.


I understand that breathwork is not advised for women who are more than four months pregnant.


Breathwork is considered an alternative healing therapy and is not a substitute for or intended to be medical or psychological care. Any advice offered regarding breathwork is not designed to be a diagnosis or treatment for any disease, injury, or medical condition. YOU MUST CONSULT YOUR PHYSICIAN OR HEALTH CARE PROVIDER regarding your health or any medical condition(s) that may affect or be impacted by breathwork.


By signing below, you agree that SoulutionCo and any of its owners, principals, agents, assistants, representatives, or employees, including but not limited to SoulutionCo and or Terah Pack (collectively, "FACILITATOR" or "RELEASED PARTIES") shall not have any liability to you under any theory of liability in connection with your participation in any breathwork activity. 


WITHOUT LIMITING THE FOREGOING, IN NO EVENT WILL THE RELEASED PARTIES BE LIABLE FOR ANY DIRECT, INDIRECT, CONSEQUENTIAL, SPECIAL, EXEMPLARY, PUNITIVE, OR INCIDENTAL DAMAGES arising from such activity.


By signing this waiver, you agree to release and forever waive any and all claims or damages you may have against the RELEASED PARTIES in connection with your participation in breathwork activities, including but not limited to any claims for damages based on FACILITATOR'S negligence. This agreement shall be binding upon you, your heirs, personal representatives, executors, and any and all successors in interest.


I (Participant) understand that I am fully and solely responsible for any effects that could potentially occur in connection with my participation in any breathwork activity administered by FACILITATOR.


I UNDERSTAND THAT PARTICIPATION IN BREATHWORK CAN EXPOSE ME TO A RISK OF PHYSICAL OR PSYCHOLOGICAL INJURY. These injuries or outcomes may arise from my own or FACILITATOR'S actions, inactions, negligence, or the condition of the location(s) or facility(ies). I ASSUME ALL RISKS OF MY PARTICIPATION IN BREATHWORK ACTIVITIES WITH FACILITATOR, WHETHER KNOWN OR UNKNOWN TO ME, OF INJURY, ILLNESS, DEATH, OR DAMAGE OF WHATEVER KIND, INCLUDING TRAVEL TO OR FROM SUCH ACTIVITY OR ANY EVENTS INCIDENTAL TO SUCH ACTIVITY. I acknowledge that I have consulted a physician and have no known health or medical conditions that would impact my ability to participate in breathwork activities administered by FACILITATOR.


I represent and certify that I am in good physical and mental health and fit to partake in breathwork activities as described above. I acknowledge that my representations constitute a material term upon which FACILITATOR is relying in permitting me to partake in ANY breathwork activities, and without such representation my participation would be denied.


On behalf of myself, my relatives, and any heirs, assigns, agents, personal representatives, and estate (collectively, the "RELEASING PARTIES"), I HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS THE RELEASED PARTIES WITH RESPECT TO ANY AND ALL INJURY, whether physical, mental, psychological, or emotional, or ANY LOSS or DAMAGE to PERSON or PROPERTY, of any kind, WHETHER ARISING FROM THE NEGLIGENCE OF FACILITATOR OR OTHERWISE, to the fullest extent permitted by law.


I agree to defend, indemnify, and hold harmless the RELEASED PARTIES for all costs and expenses, including but not limited to all legal fees incurred by RELEASED PARTIES in defending any claim brought against them by any of the RELEASING PARTIES and further agree to pay the full amount of any judgment, award, or verdict that might be entered against the RELEASED PARTIES.


I understand and acknowledge that the FACILITATOR/RELEASED PARTIES are NOT physicians or healthcare professionals, and the breathwork activities being offered are not intended to treat or diagnose any illnesses, disease, or disorders, whether physical, mental, psychological, or emotional.


I unconditionally and irrevocably waive and release any and all claims I now have or may in the future have against FACILITATOR with respect to any injury, loss, or damage I suffer as a result of participating in the breathwork activities described herein. I understand and agree that this Release of Liability, Waiver, and Assumption of Risk Agreement (hereinafter "AGREEMENT") extends to and includes any and all damages, injuries, and claims which I do not anticipate or know to exist and to any and all damages, injuries, or claims which may develop in the future, and I hereby expressly waive and relinquish any and all rights under any law or statute to the contrary.


I hereby acknowledge and agree that I am participating in a session provided by SoulutionCo and owner Terah Pack and that I have been informed that any recordings of the session, including but not limited to audio or visual recordings, are strictly prohibited. I understand that any unauthorized recording or distribution of the session, whether through personal recording devices, live streaming, or any other means, is strictly prohibited and may result in legal action being taken by SoulutionCo. I further acknowledge and agree that SoulutionCo owns all intellectual property rights to the content of the session, including but not limited to any materials, presentations, or other media used during the session. Any use or distribution of these materials without prior written consent from SoulutionCo , is strictly prohibited. By participating in the session, I agree to the terms and conditions set forth in this waiver and acknowledge that any violation of these terms may result in legal action being taken by SoulutionCo. 


Waiver of Liability Relating to COVID-19: I acknowledge the contagious nature of coronavirus/COVID-19, that public health authorities may recommend practicing physical distancing or avoiding public or group activities altogether, and that I may become infected with coronavirus/COVID-19 or other infectious disease(s) as a result of participating in breathwork activities with FACILITATOR.


Nevertheless, I voluntarily seek to participate, regardless of whether the FACILITATOR or any other person at the premises is or is not following recommended public health guidelines, and I acknowledge that I am increasing my risk of exposure by doing so. I will not participate in any activity with FACILITATOR if: (i) I am experiencing any symptom of coronavirus/COVID-19, including but not limited to cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, headache, sore throat, or loss of taste or smell; (ii) I have been exposed to someone with a suspected and/or confirmed case of coronavirus/COVID-19; or (iii) I have been diagnosed with or tested positive for coronavirus/COVID-19.


If I should become injured while participating in any breathwork activity, I authorize any licensed physician, nurse, or other medical personnel to perform emergency or surgical treatment as in his or her sole judgment may be necessary. If I need medical treatment or require any other intervention following breathwork activity, I agree that I am entirely (100%) financially responsible for any fees or costs incurred as a result.


I further declare that I am eighteen years old and legally competent to sign this liability release. I have read this AGREEMENT and am signing it freely. I have sought independent legal advice and/or understand the legal consequences of signing this document, including (a) releasing the FACILITATOR from any and all liability with respect to breathwork activity, (b) waiving my right to recover any damages with respect to breathwork activity with the FACILITATOR under any legal theory, and (c) assuming all risks of participating in breathwork activity administered by FACILITATOR.


In the event that any of the foregoing provisions are held by a court of law to be invalid or unenforceable, I agree that the total liability of FACILITATOR, if any, for losses or damages shall not exceed the amount paid for breathwork services


By signing below, you are confirming that you have read and agree to the above waiver terms.


---


Emergency Resources


SPIRITUAL EMERGENCY NETWORK (SEN):  

SEN was founded as the Spiritual Emergency Network (SEN) in 1980 by Christina Grof and her husband, Stanislav Grof, in response to the lack of understanding and respect for psychospiritual growth in the mental health profession. SEN can help you locate a mental health professional who can assist you in your spiritual growth and processing.  

http://www.spiritualemergence.org (http://www.spiritualemergence.org)


FIRESIDE PROJECT:  

If you need assistance processing your experience or ever find yourself or a loved one in a "bad trip," you can contact Fireside Project. This is a free psychedelic peer support line available through call or text at (623) 473-7433.


7 CUPS:  

7Cups.com has resources available 24/7 to chat with you and lend a friendly ear if you ever just need someone to talk to. They truly understand the powerful healing that can take place by listening to someone. It's anonymous and completely free.


RAINN:  

The nation's largest organization fighting sexual violence, RAINN also carries out programs to prevent sexual violence, help victims, and ensure that rapists are brought to justice. Rape Abuse and Incest National Network RAINN (800) 656-HOPE.


OTHER HELPFUL RESOURCES:  

National Suicide Prevention Lifeline: (800) 273-8255  

National Institute of Mental Health, Depression & Panic Disorder Hotline: (800) 421-4211  

National Center for Post-Traumatic Stress Disorder: (802) 296-6300  

American Trauma Society: (800) 556-7890  

Relapse Prevention Hotline: (800) RELAPSE.

First Participant's Name
First Name*
Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Information
Describe your current emotional blocks that you would like to resolve:
Do you have pain in the body? Where? How strong?
Describe all the physical symptoms you are currently or regularly suffering from:
What is currently the biggest source of conflict in your life right now?
What is currently your biggest stress factor?
What are 3 things you believe about yourself * that are probably not true.
From a young age, how was the relationship to your Mother?
From a young age, how was the relationship * to your Father / rest of the family?
What were the 3 most impactful events in your life?
Briefly describe your childhood.
What did your younger self start to believe about life and the world because of these repeating events?
What is something that keeps repeating in your life?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
How frequently are your comfortable emotional states? I feel good almost all the time (1-10, with 1 being low and 10 being high).
How intense are your emotional triggers? The emotions are felt in a subtle way. I am aware of them as I allow them to pass through me (1-10, with 1 being low and 10 being high).
Do those comfortable feelings last long? No constantly changing (1-10 1 being low and 10 being high)
What is the quality of your comfortable emotional states at presently (1-10 1 being low and 10 being high)
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will save, fix or heal any of my problems or symptoms for me.*
No
Yes
I understand that my life cannot change unless I take ownership of my own emotional process and the decision I make in life.*
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work * is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
I am aware that this may bring up destabilizing emotional material such as helplessness or powerless that could potential linger up to a couple days/weeks after the session.*
No
Yes
I am aware that as part of a normal process, symptoms and emotions can sometimes get worse before they get better.*
No
Yes
I am mature enough to witness and hold myself in these difficult states. I trust that all of this is part of the healing process and I will reach out to my Release-Guide if I need assistance.*
No
Yes
I will not isolate myself in my own process and I will communicate when I need assistance.*
No
Yes
I am aware that the emotions released in the * session could trigger stories, projections and drama within me. I will attempt to discern my own protective patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I am ready to trust and surrender to my body * intelligence to go through this deep process.*
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Describe your current emotional blocks that you would like to resolve:
Do you have pain in the body? Where? How strong?
Describe all the physical symptoms you are currently or regularly suffering from:
What is currently the biggest source of conflict in your life right now?
What is currently your biggest stress factor?
What are 3 things you believe about yourself * that are probably not true.
From a young age, how was the relationship to your Mother?
From a young age, how was the relationship * to your Father / rest of the family?
What were the 3 most impactful events in your life?
Briefly describe your childhood.
What did your younger self start to believe about life and the world because of these repeating events?
What is something that keeps repeating in your life?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
How frequently are your comfortable emotional states? I feel good almost all the time (1-10, with 1 being low and 10 being high).
How intense are your emotional triggers? The emotions are felt in a subtle way. I am aware of them as I allow them to pass through me (1-10, with 1 being low and 10 being high).
Do those comfortable feelings last long? No constantly changing (1-10 1 being low and 10 being high)
What is the quality of your comfortable emotional states at presently (1-10 1 being low and 10 being high)
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will save, fix or heal any of my problems or symptoms for me.*
No
Yes
I understand that my life cannot change unless I take ownership of my own emotional process and the decision I make in life.*
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work * is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
I am aware that this may bring up destabilizing emotional material such as helplessness or powerless that could potential linger up to a couple days/weeks after the session.*
No
Yes
I am aware that as part of a normal process, symptoms and emotions can sometimes get worse before they get better.*
No
Yes
I am mature enough to witness and hold myself in these difficult states. I trust that all of this is part of the healing process and I will reach out to my Release-Guide if I need assistance.*
No
Yes
I will not isolate myself in my own process and I will communicate when I need assistance.*
No
Yes
I am aware that the emotions released in the * session could trigger stories, projections and drama within me. I will attempt to discern my own protective patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I am ready to trust and surrender to my body * intelligence to go through this deep process.*
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Describe your current emotional blocks that you would like to resolve:
Do you have pain in the body? Where? How strong?
Describe all the physical symptoms you are currently or regularly suffering from:
What is currently the biggest source of conflict in your life right now?
What is currently your biggest stress factor?
What are 3 things you believe about yourself * that are probably not true.
From a young age, how was the relationship to your Mother?
From a young age, how was the relationship * to your Father / rest of the family?
What were the 3 most impactful events in your life?
Briefly describe your childhood.
What did your younger self start to believe about life and the world because of these repeating events?
What is something that keeps repeating in your life?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
How frequently are your comfortable emotional states? I feel good almost all the time (1-10, with 1 being low and 10 being high).
How intense are your emotional triggers? The emotions are felt in a subtle way. I am aware of them as I allow them to pass through me (1-10, with 1 being low and 10 being high).
Do those comfortable feelings last long? No constantly changing (1-10 1 being low and 10 being high)
What is the quality of your comfortable emotional states at presently (1-10 1 being low and 10 being high)
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will save, fix or heal any of my problems or symptoms for me.*
No
Yes
I understand that my life cannot change unless I take ownership of my own emotional process and the decision I make in life.*
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work * is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
I am aware that this may bring up destabilizing emotional material such as helplessness or powerless that could potential linger up to a couple days/weeks after the session.*
No
Yes
I am aware that as part of a normal process, symptoms and emotions can sometimes get worse before they get better.*
No
Yes
I am mature enough to witness and hold myself in these difficult states. I trust that all of this is part of the healing process and I will reach out to my Release-Guide if I need assistance.*
No
Yes
I will not isolate myself in my own process and I will communicate when I need assistance.*
No
Yes
I am aware that the emotions released in the * session could trigger stories, projections and drama within me. I will attempt to discern my own protective patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I am ready to trust and surrender to my body * intelligence to go through this deep process.*
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Describe your current emotional blocks that you would like to resolve:
Do you have pain in the body? Where? How strong?
Describe all the physical symptoms you are currently or regularly suffering from:
What is currently the biggest source of conflict in your life right now?
What is currently your biggest stress factor?
What are 3 things you believe about yourself * that are probably not true.
From a young age, how was the relationship to your Mother?
From a young age, how was the relationship * to your Father / rest of the family?
What were the 3 most impactful events in your life?
Briefly describe your childhood.
What did your younger self start to believe about life and the world because of these repeating events?
What is something that keeps repeating in your life?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
How frequently are your comfortable emotional states? I feel good almost all the time (1-10, with 1 being low and 10 being high).
How intense are your emotional triggers? The emotions are felt in a subtle way. I am aware of them as I allow them to pass through me (1-10, with 1 being low and 10 being high).
Do those comfortable feelings last long? No constantly changing (1-10 1 being low and 10 being high)
What is the quality of your comfortable emotional states at presently (1-10 1 being low and 10 being high)
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will save, fix or heal any of my problems or symptoms for me.*
No
Yes
I understand that my life cannot change unless I take ownership of my own emotional process and the decision I make in life.*
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work * is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
I am aware that this may bring up destabilizing emotional material such as helplessness or powerless that could potential linger up to a couple days/weeks after the session.*
No
Yes
I am aware that as part of a normal process, symptoms and emotions can sometimes get worse before they get better.*
No
Yes
I am mature enough to witness and hold myself in these difficult states. I trust that all of this is part of the healing process and I will reach out to my Release-Guide if I need assistance.*
No
Yes
I will not isolate myself in my own process and I will communicate when I need assistance.*
No
Yes
I am aware that the emotions released in the * session could trigger stories, projections and drama within me. I will attempt to discern my own protective patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I am ready to trust and surrender to my body * intelligence to go through this deep process.*
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Describe your current emotional blocks that you would like to resolve:
Do you have pain in the body? Where? How strong?
Describe all the physical symptoms you are currently or regularly suffering from:
What is currently the biggest source of conflict in your life right now?
What is currently your biggest stress factor?
What are 3 things you believe about yourself * that are probably not true.
From a young age, how was the relationship to your Mother?
From a young age, how was the relationship * to your Father / rest of the family?
What were the 3 most impactful events in your life?
Briefly describe your childhood.
What did your younger self start to believe about life and the world because of these repeating events?
What is something that keeps repeating in your life?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
How frequently are your comfortable emotional states? I feel good almost all the time (1-10, with 1 being low and 10 being high).
How intense are your emotional triggers? The emotions are felt in a subtle way. I am aware of them as I allow them to pass through me (1-10, with 1 being low and 10 being high).
Do those comfortable feelings last long? No constantly changing (1-10 1 being low and 10 being high)
What is the quality of your comfortable emotional states at presently (1-10 1 being low and 10 being high)
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will save, fix or heal any of my problems or symptoms for me.*
No
Yes
I understand that my life cannot change unless I take ownership of my own emotional process and the decision I make in life.*
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work * is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
I am aware that this may bring up destabilizing emotional material such as helplessness or powerless that could potential linger up to a couple days/weeks after the session.*
No
Yes
I am aware that as part of a normal process, symptoms and emotions can sometimes get worse before they get better.*
No
Yes
I am mature enough to witness and hold myself in these difficult states. I trust that all of this is part of the healing process and I will reach out to my Release-Guide if I need assistance.*
No
Yes
I will not isolate myself in my own process and I will communicate when I need assistance.*
No
Yes
I am aware that the emotions released in the * session could trigger stories, projections and drama within me. I will attempt to discern my own protective patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I am ready to trust and surrender to my body * intelligence to go through this deep process.*
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Describe your current emotional blocks that you would like to resolve:
Do you have pain in the body? Where? How strong?
Describe all the physical symptoms you are currently or regularly suffering from:
What is currently the biggest source of conflict in your life right now?
What is currently your biggest stress factor?
What are 3 things you believe about yourself * that are probably not true.
From a young age, how was the relationship to your Mother?
From a young age, how was the relationship * to your Father / rest of the family?
What were the 3 most impactful events in your life?
Briefly describe your childhood.
What did your younger self start to believe about life and the world because of these repeating events?
What is something that keeps repeating in your life?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
How frequently are your comfortable emotional states? I feel good almost all the time (1-10, with 1 being low and 10 being high).
How intense are your emotional triggers? The emotions are felt in a subtle way. I am aware of them as I allow them to pass through me (1-10, with 1 being low and 10 being high).
Do those comfortable feelings last long? No constantly changing (1-10 1 being low and 10 being high)
What is the quality of your comfortable emotional states at presently (1-10 1 being low and 10 being high)
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will save, fix or heal any of my problems or symptoms for me.*
No
Yes
I understand that my life cannot change unless I take ownership of my own emotional process and the decision I make in life.*
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work * is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
I am aware that this may bring up destabilizing emotional material such as helplessness or powerless that could potential linger up to a couple days/weeks after the session.*
No
Yes
I am aware that as part of a normal process, symptoms and emotions can sometimes get worse before they get better.*
No
Yes
I am mature enough to witness and hold myself in these difficult states. I trust that all of this is part of the healing process and I will reach out to my Release-Guide if I need assistance.*
No
Yes
I will not isolate myself in my own process and I will communicate when I need assistance.*
No
Yes
I am aware that the emotions released in the * session could trigger stories, projections and drama within me. I will attempt to discern my own protective patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I am ready to trust and surrender to my body * intelligence to go through this deep process.*
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Describe your current emotional blocks that you would like to resolve:
Do you have pain in the body? Where? How strong?
Describe all the physical symptoms you are currently or regularly suffering from:
What is currently the biggest source of conflict in your life right now?
What is currently your biggest stress factor?
What are 3 things you believe about yourself * that are probably not true.
From a young age, how was the relationship to your Mother?
From a young age, how was the relationship * to your Father / rest of the family?
What were the 3 most impactful events in your life?
Briefly describe your childhood.
What did your younger self start to believe about life and the world because of these repeating events?
What is something that keeps repeating in your life?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
How frequently are your comfortable emotional states? I feel good almost all the time (1-10, with 1 being low and 10 being high).
How intense are your emotional triggers? The emotions are felt in a subtle way. I am aware of them as I allow them to pass through me (1-10, with 1 being low and 10 being high).
Do those comfortable feelings last long? No constantly changing (1-10 1 being low and 10 being high)
What is the quality of your comfortable emotional states at presently (1-10 1 being low and 10 being high)
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will save, fix or heal any of my problems or symptoms for me.*
No
Yes
I understand that my life cannot change unless I take ownership of my own emotional process and the decision I make in life.*
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work * is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
I am aware that this may bring up destabilizing emotional material such as helplessness or powerless that could potential linger up to a couple days/weeks after the session.*
No
Yes
I am aware that as part of a normal process, symptoms and emotions can sometimes get worse before they get better.*
No
Yes
I am mature enough to witness and hold myself in these difficult states. I trust that all of this is part of the healing process and I will reach out to my Release-Guide if I need assistance.*
No
Yes
I will not isolate myself in my own process and I will communicate when I need assistance.*
No
Yes
I am aware that the emotions released in the * session could trigger stories, projections and drama within me. I will attempt to discern my own protective patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I am ready to trust and surrender to my body * intelligence to go through this deep process.*
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Describe your current emotional blocks that you would like to resolve:
Do you have pain in the body? Where? How strong?
Describe all the physical symptoms you are currently or regularly suffering from:
What is currently the biggest source of conflict in your life right now?
What is currently your biggest stress factor?
What are 3 things you believe about yourself * that are probably not true.
From a young age, how was the relationship to your Mother?
From a young age, how was the relationship * to your Father / rest of the family?
What were the 3 most impactful events in your life?
Briefly describe your childhood.
What did your younger self start to believe about life and the world because of these repeating events?
What is something that keeps repeating in your life?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
How frequently are your comfortable emotional states? I feel good almost all the time (1-10, with 1 being low and 10 being high).
How intense are your emotional triggers? The emotions are felt in a subtle way. I am aware of them as I allow them to pass through me (1-10, with 1 being low and 10 being high).
Do those comfortable feelings last long? No constantly changing (1-10 1 being low and 10 being high)
What is the quality of your comfortable emotional states at presently (1-10 1 being low and 10 being high)
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will save, fix or heal any of my problems or symptoms for me.*
No
Yes
I understand that my life cannot change unless I take ownership of my own emotional process and the decision I make in life.*
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work * is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
I am aware that this may bring up destabilizing emotional material such as helplessness or powerless that could potential linger up to a couple days/weeks after the session.*
No
Yes
I am aware that as part of a normal process, symptoms and emotions can sometimes get worse before they get better.*
No
Yes
I am mature enough to witness and hold myself in these difficult states. I trust that all of this is part of the healing process and I will reach out to my Release-Guide if I need assistance.*
No
Yes
I will not isolate myself in my own process and I will communicate when I need assistance.*
No
Yes
I am aware that the emotions released in the * session could trigger stories, projections and drama within me. I will attempt to discern my own protective patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I am ready to trust and surrender to my body * intelligence to go through this deep process.*
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Describe your current emotional blocks that you would like to resolve:
Do you have pain in the body? Where? How strong?
Describe all the physical symptoms you are currently or regularly suffering from:
What is currently the biggest source of conflict in your life right now?
What is currently your biggest stress factor?
What are 3 things you believe about yourself * that are probably not true.
From a young age, how was the relationship to your Mother?
From a young age, how was the relationship * to your Father / rest of the family?
What were the 3 most impactful events in your life?
Briefly describe your childhood.
What did your younger self start to believe about life and the world because of these repeating events?
What is something that keeps repeating in your life?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
How frequently are your comfortable emotional states? I feel good almost all the time (1-10, with 1 being low and 10 being high).
How intense are your emotional triggers? The emotions are felt in a subtle way. I am aware of them as I allow them to pass through me (1-10, with 1 being low and 10 being high).
Do those comfortable feelings last long? No constantly changing (1-10 1 being low and 10 being high)
What is the quality of your comfortable emotional states at presently (1-10 1 being low and 10 being high)
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will save, fix or heal any of my problems or symptoms for me.*
No
Yes
I understand that my life cannot change unless I take ownership of my own emotional process and the decision I make in life.*
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work * is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
I am aware that this may bring up destabilizing emotional material such as helplessness or powerless that could potential linger up to a couple days/weeks after the session.*
No
Yes
I am aware that as part of a normal process, symptoms and emotions can sometimes get worse before they get better.*
No
Yes
I am mature enough to witness and hold myself in these difficult states. I trust that all of this is part of the healing process and I will reach out to my Release-Guide if I need assistance.*
No
Yes
I will not isolate myself in my own process and I will communicate when I need assistance.*
No
Yes
I am aware that the emotions released in the * session could trigger stories, projections and drama within me. I will attempt to discern my own protective patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I am ready to trust and surrender to my body * intelligence to go through this deep process.*
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Describe your current emotional blocks that you would like to resolve:
Do you have pain in the body? Where? How strong?
Describe all the physical symptoms you are currently or regularly suffering from:
What is currently the biggest source of conflict in your life right now?
What is currently your biggest stress factor?
What are 3 things you believe about yourself * that are probably not true.
From a young age, how was the relationship to your Mother?
From a young age, how was the relationship * to your Father / rest of the family?
What were the 3 most impactful events in your life?
Briefly describe your childhood.
What did your younger self start to believe about life and the world because of these repeating events?
What is something that keeps repeating in your life?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
How frequently are your comfortable emotional states? I feel good almost all the time (1-10, with 1 being low and 10 being high).
How intense are your emotional triggers? The emotions are felt in a subtle way. I am aware of them as I allow them to pass through me (1-10, with 1 being low and 10 being high).
Do those comfortable feelings last long? No constantly changing (1-10 1 being low and 10 being high)
What is the quality of your comfortable emotional states at presently (1-10 1 being low and 10 being high)
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will save, fix or heal any of my problems or symptoms for me.*
No
Yes
I understand that my life cannot change unless I take ownership of my own emotional process and the decision I make in life.*
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work * is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
I am aware that this may bring up destabilizing emotional material such as helplessness or powerless that could potential linger up to a couple days/weeks after the session.*
No
Yes
I am aware that as part of a normal process, symptoms and emotions can sometimes get worse before they get better.*
No
Yes
I am mature enough to witness and hold myself in these difficult states. I trust that all of this is part of the healing process and I will reach out to my Release-Guide if I need assistance.*
No
Yes
I will not isolate myself in my own process and I will communicate when I need assistance.*
No
Yes
I am aware that the emotions released in the * session could trigger stories, projections and drama within me. I will attempt to discern my own protective patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I am ready to trust and surrender to my body * intelligence to go through this deep process.*
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Information
Describe your current emotional blocks that you would like to resolve:
Do you have pain in the body? Where? How strong?
Describe all the physical symptoms you are currently or regularly suffering from:
What is currently the biggest source of conflict in your life right now?
What is currently your biggest stress factor?
What are 3 things you believe about yourself * that are probably not true.
From a young age, how was the relationship to your Mother?
From a young age, how was the relationship * to your Father / rest of the family?
What were the 3 most impactful events in your life?
Briefly describe your childhood.
What did your younger self start to believe about life and the world because of these repeating events?
What is something that keeps repeating in your life?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
How frequently are your comfortable emotional states? I feel good almost all the time (1-10, with 1 being low and 10 being high).
How intense are your emotional triggers? The emotions are felt in a subtle way. I am aware of them as I allow them to pass through me (1-10, with 1 being low and 10 being high).
Do those comfortable feelings last long? No constantly changing (1-10 1 being low and 10 being high)
What is the quality of your comfortable emotional states at presently (1-10 1 being low and 10 being high)
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will save, fix or heal any of my problems or symptoms for me.*
No
Yes
I understand that my life cannot change unless I take ownership of my own emotional process and the decision I make in life.*
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work * is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
I am aware that this may bring up destabilizing emotional material such as helplessness or powerless that could potential linger up to a couple days/weeks after the session.*
No
Yes
I am aware that as part of a normal process, symptoms and emotions can sometimes get worse before they get better.*
No
Yes
I am mature enough to witness and hold myself in these difficult states. I trust that all of this is part of the healing process and I will reach out to my Release-Guide if I need assistance.*
No
Yes
I will not isolate myself in my own process and I will communicate when I need assistance.*
No
Yes
I am aware that the emotions released in the * session could trigger stories, projections and drama within me. I will attempt to discern my own protective patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I am ready to trust and surrender to my body * intelligence to go through this deep process.*
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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