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Private Session Request

Whether you're looking for a private RESET or a deeper 1:1 experience, this form helps me understand what you're looking for, find a suitable time and make sure the session is appropriate for you.

Please complete the form before requesting your session.

Your Booking

Which session are you interested in?*

RESET Private | 45 minutes · $85

Beneath the Surface | 75 minutes $140

Your Details

Full Name*

Email*

Phone*

Your Session

Have you experienced breathwork before?*

No, this is new to me

Yes, a little

Yes, regularly

I'm not sure

What are you hoping to receive from your session?*

Stress relief

Nervous system regulation

Relaxation

Emotional release

Feeling more connected to myself

Releasing physical tension

I'm not really sure, I just feel called to do this

Something else

Is there something specific you'd like to explore or receive support with?

Your Wellbeing

Breathwork can create strong physical, emotional and nervous system responses. These questions help me determine whether the practice is suitable for you and whether any modifications or additional care may be needed.

Do you currently have, or have you ever been diagnosed with, any of the following?*

Cardiovascular or heart condition

High blood pressure

Seizures /epilepsy

Respiratory condition (eg. Asthma)

History of fainting

Recent surgery or significant injury

Pregnancy

Glaucoma or retinal problems

Osteoporosis

Serious mental health condition or psychiatric diagnosis

Any other medical condition I should be aware of

None of the above

Are you currently taking any medications that may affect your breathing, blood pressure, heart rate, consciousness or nervous system?*

Yes

No

If yes, please tell me which medications and anything you think I should know

Is there anything about your physical or emotional wellbeing that you feel I should know before working with you?

Bodywork + Energy Work

Depending on your intention and what feels appropriate during your session, gentle hands on bodywork and/or energy work may be offered as part of your experience.

Are you comfortable with gentle hands-on bodywork being incorporated into your session?*

Yes

No

I'd like to discuss this first

Are you comfortable with energy work being incorporated into your session?*

Yes

No

I'd like to discuss this first

Are there any areas of your body you would prefer not to have touched, or anything you would like me to be aware of around physical contact?

Is there anything else you'd like me to know about your boundaries, preferences or comfort before we work together?

I understand that any bodywork or energy work offered during my session is optional and that I can ask for it to be modified or stopped at any time.

I consent to bodywork and/or energy work being offered as part of my session, according to my preferences above and consent on the day.

Finding A Time

Once request has been received, I will be in touch to arrange session time directly.

Please give me a few options that generally work for you and I'll do my best to find a time that fits.

Please remember that your preferred time isn't confirmed until I have confirmed it with you.

What days generally work for you?*

Monday evening

Tuesday evening

Wednesday evening

Thursday evening

Friday evening

Saturday

Sunday

Please provide 2–3 preferred dates/times*

Please submit your request at least 48 hours before your preferred session date.

Discount Code

Please enter any discount code you wish to use.

I'll apply any valid discount to your booking before sending your payment request.

Discount codes are subject to their individual terms and cannot be applied after payment has been processed.

Emergency Contact

Please provide the details of someone we can contact in the unlikely event of an emergency or if we are unable to reach you following your session.

Name*

Relationship to you*

Phone Number*

Confirmation

I confirm that the information I've provided is accurate and complete to the best of my knowledge.

I understand that submitting this form is a request only and does not confirm my session. My session will be confirmed once Stacey has reviewed my request, we have agreed on a suitable time and payment has been received.

A space to breathe.

A space to feel.

A space to come back to yourself.

hello@somaandsolas.com.au

Hawkesbury, NSW

Terms & Conditions

Refund and Cancellation Policy

Somatic Breathwork · Bodywork · Energy Work · Western Sydney

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