Practitioner Directory Listing Application

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Breathwork Practitioner -Directory Listing Application Cost: $10 USD per year
Please note that all fields followed by an asterisk must be filled in.
First Name* First Name*
Last Name* Last Name*
E-mail Address* E-mail Address*
Web Site URL
Street Address* Street Address*
City* City*
State/Prov* State/Prov*
Zip/Postal Code* Zip/Postal Code*
Country* Country*
Home Phone
Business Phone
What is your Experience with Conscious Breathing? What are your qualifications? What trainings have you attended? ...etc.* What is your Experience with Conscious Breathing? What are your qualifications? What trainings have you attended? ...etc.*
What year did you become a practitoner?* What year did you become a practitoner?*
Name of your Business or Organization, if applicable.
Are you a non-profit Organization?
Area of focus, what do you specialize in?
What is your personal approach to Breathwork?
Do you offer wet Rebirthing? Hot or cold?
Do you offer ongoing Support Groups for your clients?
Are there other healing modalities you are trained in?
Who is your ideal client? (what specific age group, gender, etc...if any)
What is your code of ethics for working with clients?
What is the average cost of one of your sessions?
Do you offer discount packages?
Have you published any books on Conscious Breathing - Rebirthing?
Anything else you would like your potential clients to know about you?
Do you have a photo you would like to include with your Directory Listing?
Would you like to be interviewed to include an audio file with your Listing?
Please enter the word that you see below.

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