Nervous System Snapshot

Pause. Reflect. Realign.

Welcome to your Nervous System Snapshot — the first step in understanding where you truly are right now.

This isn’t just a form. It’s an opportunity to slow down, check in with yourself, and create awareness around what your mind, body, and breath have been carrying.

In this short reflection, you’ll explore:
✨ Your current stress levels
✨ How tension and pressure show up in your body and mind
✨ The daily challenges you’re navigating
✨ Your energy, sleep, and coping patterns
✨ Your functional breathing patterns

Why it matters:
Self-awareness is the starting point for meaningful change. Your honest reflections here give us a clear foundation to build from as you step into this journey of breaking patterns, regulating your nervous system, and reconnecting with who you truly are.

There’s no right or wrong—just your truth.
Take a slow breath, settle into yourself, and begin.

Your journey starts here.

First Name *

Last Name *

Phone *

Email *

What is motivating you to explore the benefits of Breathwork? *

How would you rate your current stress levels? *

1 = Not stressed at all | 10 = Extremely stressed

Please explain what areas contribute most to your stress rating (e.g. Family pressure, work demands, health, financial or Work/Career) * Provide as much detail as you feel comfortable doing *

How does stress typically manifest in your body? (e.g., headaches, muscle tension, sleep issues) *

What’s your biggest challenge that you’re facing day-to-day? *

How effective are you at managing your stress on a scale? *

1 = Unable to manage stress | 10 = No problem managing stress

If other please specify.

How would you describe your energy levels throughout a typical day? *

1 = Very low energy | 10 = Very high energy

When you feel stressed, what is your default coping mechanism? *

How good is the quality of your sleep?

1 = Very Poor | 10 = Very Good

On average, how many hours of sleep do you get each night? *

When was the last time you felt truly relaxed, and what were you doing? *

What specific support or tools do you believe would help you manage stress better? *

How would you rate your mental clarity? *

1 = Brain fog everyday | 10 = Always Clear

Have you had any traumatic events occur in recent times? *

Yes

Do you have any history of childhood trauma? *

Yes

Do you often feel like you’re racing to keep up or can’t slow down? *

Racing to Keep up

Can't slow down

When life feels overwhelming, do you tend to shut down or “check out”? *

Yes

Please provide any further details you believe would help me understand your current situation. *

Functional Breathing

Our breath is the remote control for our nervous system.
By understanding how we breathe, we can quickly identify areas for improvement that lead to faster regulation, better resilience, and improved overall wellbeing. These questions will help us assess your current breathing patterns so we can tailor your program to your needs.

Set a timer for 1 min and count how many times you take a breath. Enter your number below (In hale and exhale = 1 Breath) *

Out of 1-10, how easy do you find it to breathe through your nose throughout the day? *

1 = Very Difficult | 10 = No Problem

Do you notice yourself breathing through your mouth during the day? *

Yes

Do you snore at night? *

Yes

Do you often wake up feeling groggy or unrested in the morning? *

Yes

Maybe

Do you wake up with a dry mouth? *

Yes

Out of 1-10, how easy is it for you to take a satisfying breath? *

1 = Very Hard | 10 = No Problem

Do you ever experience feelings of breathlessness or feel like you're not getting enough air? *

Yes

Do you ever notice or hear yourself breathing, either during the day or night? *

Yes

Do you sigh often? *

Yes

Do you yawn often? *

Yes

Do you find yourself holding your breath during certain activities or situations? *

Yes

Do you experience tightness in your chest, especially during stress? *

Yes

How often do you feel like your breathing is shallow or restricted? *

Daily

Occasionally

Rarely

Never

Do you feel like stress or anxiety impacts your breathing? *

Yes

Have you ever done any forms of Breathwork before? If so, what was your experience like? *

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