12-Week Waybook Process Intake Form

Thank you for your interest in this 12-week journey of self-inquiry, presence, and preparation for holding space. This form helps ensure the process is aligned, supportive, and safe for you and the group. Please answer honestly—there are no right or wrong answers.
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1. Full Name
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2. Email Address
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3. Age
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4. Current Location (City/Country)
Your Intention
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5. What is calling you to join this 12-week process at this time
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6. What are you hoping to explore, understand, or shift within yourself
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7. Are you interested in eventually becoming a breathwork facilitator, or is this purely for personal growth (no commitment required, just your current feeling)
Interested in eventually becoming a breathwork facilitator
Purely for personal growth at this time
Self-Awareness & Inner Work
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8. Have you done any form of self-development, therapy, breathwork, or similar practices before
Yes
No
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9. Please briefly describe your prior and or current daily practices

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10. How would you describe your relationship with your emotions?

Mental & Emotional Health
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11. Have you ever been diagnosed with or experienced any of the following (please select all that apply)[Checkboxes]
PTSD
Bipolar disorder
Severe anxiety or panic attacks
Depression
Other (please specify)
None
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12. Please specify 'other 'condition if applicable
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13. Are you currently receiving any form of psychological or psychiatric support
Yes
No
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14. Please briefly describe your current support
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15. Is there anything about your mental or emotional health that you feel is important for me to know
Capacity & Commitment
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16. Are you able to commit to the live weekly sessions over the 12 weeks (occasional absences are acceptable)
Yes, I am able to commit
No, I cannot commit to this schedule at this time
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17. Are you open to engaging in light daily practices including breath awareness, journaling, and reflection
Yes, I am open to this
No, I am not able to engage in daily practices at this time
Relational Awareness
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18. Do you feel comfortable sharing and being witnessed in a group setting
Very comfortable
Somewhat comfortable
Neutral
Somewhat uncomfortable
Very uncomfortable
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19. What challenges, if any, do you experience in relationships or communication
Boundaries & Responsibility
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20. This process involves self-inquiry and emotional exploration. Are you willing to take responsibility for your own experience within the container
Yes, I am willing to take responsibility
No, I am not willing at this time
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21. Are you open to receiving guidance and reflection, even if it challenges your current perspective
Yes, I am open to this
No, I prefer not to receive challenging guidance at this time
Final Reflection
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22. Why do you feel this is the right time for you to enter this process
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23. Is there anything else you would like to share before we connect
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