breathwork Consent Form

This form contains information to help you make informed decisions about wellness services with Family of Choice LLC, contracted with and provided by Ivy Brotherton, RYT-200hr, ACE Certified Personal Trainer and Nutrition Coach with BADASS Nutrition Coaching LLC.

This Wellness Services Client Agreement / Contract (hereafter referred to as "The Agreement") constitutes a contract between Family of Choice LLC (hereafter referred to individually as the "Provider"), Ivy Brotherton (the "facilitator"), and the Undersigned, yourself as indicated on the signature page (hereafter referred to as the "Client"). 

AS THE CLIENT, YOU SHOULD READ IT CAREFULLY AND RAISE ANY QUESTIONS AND/OR CONCERNS PRIOR TO SIGNING THIS AGREEMENT.  

Family of Choice LLC offers multiple programs to include Reiki, Sound Healing, Breathwork, Coaching and Prevention Services. 

Purpose and Benefits

The session aims to promote relaxation, reduce stress, and enhance overall wellbeing through conscious breathing techniques. Breathwork is not therapy. It falls under the umbrella of Yoga and the limb of Pranayama, or breathing techniques for healing mind and body.

Scope of Engagement

The Client chooses and agrees to participate fully in the Wellness Services selected below. The provider is here to help, guide, advise and support the Client as well as to review any work that is completed during the program. The Client acknowledges that the Program is designed to transform and help Clients grow as a person and in their business. In order to grow, people often need to face the possibility of unpleasant things and be pushed out of their comfort zone, and the Client agrees to be open to such experiences throughout the course of the transformation. The provider may terminate or change the terms of this Agreement at any time in its discretion upon notice to the Client if they feel that the professional relationship is not respectful. The Client understands that any failure on their part to complete the action steps in full throughout the program will result in possibly not receiving the full benefit of the program. All practitioners are certified to provide the service. You may request details on their certification and training at any time.

Risks and Contraindications

Breathwork may involve intense emotional releases, physical sensations or altered states of consciousness. While rare, potential risks include: 1. Emotional distress or triggering, 2. Physical discomfort or pain, 3. Dizziness or lightheadedness.

Contraindications

1. Pregnancy or recent surgery, 2. Severe mental health conditions (e.g. psychosis, bipolar disorder), 3. Epilepsy or seizure disorders, 4. Severe physical limitations or disabilities.

Participant Responsibilities

1. Disclose medical history, mental health conditions and medications, 2. Inform facilitator of discomfort or distress, 3. Follow facilitator's guidance

Facilitator Responsibilities

1. Provide a safe and supportive environment, 2. monitor participant wellbeing, 3. Adapt techniques for individual needs.

Facilitator Scope of Practice

Ivy Brotherton is NOT a licensed therapist. She is a 200 hour registered Yoga Teacher and ECA Certified Personal Trainer and Nutrition Coach. She completed Brainspotting Phase 1 Training in October 2024 and is under supervision on learning to utilize this modality in her breathwork coaching sessions.

Release and Waiver

I release and hold harmless the Facilitator, the assistants, and affiliated organizations from liability for any damages arising from the Session.

Payment & Billing

I UNDERSTAND AND AGREE TO THE FOLLOWING: Your bill is due at the time of service. Breathwork services are non-refundable. If for some reason I have created a balance on my account, further services will not be provided until the balance is paid in full. 

Cancellation Fees

The Term of this Agreement will commence upon YOUR acceptance of this Agreement. You further acknowledge that in accepting the terms of this Agreement and affirmatively seeking the benefits YOU are taking full responsibility for YOUR OWN success. 

Limits to Confidentiality

All information from sessions is confidential with some exceptions because of our provider's other qualifications as qualified or licensed mental health professionals. Exceptions to confidentiality are (a) When information pertains to child or elder abuse or neglect, (b) When a client brings charges against the practitioner, (c) When the practitioner is called upon to testify in court or hearings about adoption, adult abuse, child abuse, child neglect or other matters pertaining to the client’s welfare, (c) When the practitioner needs to prevent a clear and immediate danger to a person or persons (suicide or homicide).

I understand any information my practitioner receives and relates to me during a Wellness Session may be literal or symbolic and that I am solely responsible for the decisions and choices I make towards healing. I understand that the services provided are completely separate from my provider's other roles as a qualified or licensed mental health professional. Wellness Services are NOT considered Therapy.

Medical Concerns

I will notify the provider of any medical concerns that I have. It is my responsibility to inform the provider and refrain from participation if I feel uncomfortable at any time. The provider does not assume liability for my physical wellbeing. I will notify the provider if I am pregnant. 

My signature below indicates that I understand and agree with the practitioner’s policies and voluntarily give informed consent to receive Wellness Services from Family of Choice LLC. I acknowledge that:  1. I understand potential risks and benefits, 2. I disclose relevant medical information, 3. I release liability.

Parents must sign for their minor children. Each participant must complete their own consent form.