Form | Freya

Name

First

Last

Address

Email

Intention for booking the process:

Are you currently pregnant? If so which trimester?

How are you feeling during the pregnancy or how do you feel about the idea of being pregnant if not already?

How has pregnancy gone for you so far? Note the specific highs and the specific lows:

Do you feel like you have a solid support network around you? (family, partner, friends, professionals) Please explain.

What tools and help would you like to obtain from your process within Mama Rise?

Do you experience any of the following?

WAIVER

I understand. The Mama Rise program is a somatic-based program in which breathwork is the main avenue used to help support your process. This process is NOT therapy, does NOT diagnose or treat any physical, mental or emotional imbalance. If you are followed by a team of therapists or a medical team, I advise you to notify them that you will be doing breathwork as part of your birth preparation and/or transition into motherhood.

By taking part in the program I take full responsibility for my journey and agree that:

* My mental-emotional balance is stable and not in critical need of clinical treatment and I assert I am in good physical condition.
* If I am followed for a physical or mental-emotional situation, I will notify my team of professionals that I am taking this program.
* I will notify the program leader if I have a severe condition before beginning the journey.
* I commit 100% to this journey and take responsibility for my own practice and integration.
* I am fully aware that the results of this journey depend on my willingness to do my work.

Release

I hereby release and agree to hold Freya and its subsidiaries harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the facilitator, or that may otherwise arise in any way in connection with any services received from Freya. I understand that this release discharges Freya from any liability or claim that I, my heirs, or any personal representatives may have against the company with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Freya. This liability waiver and release extends to the company together with all owners, partners, and employees.

Mama Rise Intake Form