BreathWay Intake Form

Have you suffered from (please click conditions):

Some symptoms may seem unrelated to poor breathing. Take this test before the course and 2 weeks after, to measure your improvement. Beside each symptom, rate yourself: 0 - never; 1 - rare; 2 - sometimes; 3 - often; 4 - very often

Adult Course fees: The 5-session course fee is $500.00. You can pay by cash, cheque, email transfer through, or credit cards on site.

Course includes: comprehensive workbook, 5 classes (each class is about 2 hours), follow-up, on-going support, can attend a refresher set of classes at no charge for up to a year from completion of initial class (when space available).

I understand that: 1) The BreathWay breath retraining course is a series of lectures and exercises. It does not constitute medical treatment. I, the undersigned, agree to only modify prescribed medication after consultation with a medical doctor. 2) As I am not a trained BreathWay Educator, I will not attempt to teach other people without first completing the training according to the BBEA guidelines. I have read this form and I understand the conditions. The information given by me is accurate.