Nervous System Reset Questionnaire

About You

Your Name *

Email Address *

Age *

Energy & Nervous System

How would you rate your overall energy levels right now? *

Completely drained / exhausted Low energy, often tired Moderate — up and down Mostly good Energised and vibrant

How often do you feel "wired but tired" (racing mind + physical exhaustion)? *

Almost never Rarely Sometimes Often Almost always

How often do you feel shut down, numb, or disconnected from your body? *

Almost never Rarely Sometimes Often Almost always

How would you rate your sleep quality? *

Terrible — very little sleep Poor — often broken Average — inconsistent Good — mostly restorative Deep and refreshing

Breathwork Experience

Have you tried breathwork before? *

Never A few times Occasionally Regularly (weekly) Daily or done courses

How did breathwork feel for you? *

Very calming Somewhat calming Neutral Activating / Energising Overwhelming or made me feel worse

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Lifestyle & Support

How would you rate your diet / nourishment? *

Very poor Quite poor Average Good Excellent

How often do you move your body in a way that feels good? *

Never Rarely Sometimes Often Daily

How would you rate your current support network? *

Very isolated Limited support Average Mostly supported Strongly supported

Current Challenges

How much financial stress are you carrying right now? *

None Mild Moderate High Extremely high

How are your anxiety levels at the moment? *

None Mild Moderate High Extremely high

Overall, how safe does your body feel right now? *

Very unsafe Unsafe Neutral Mostly safe Very safe

Your Goals

What is your biggest struggle right now? *

What would "feeling better" look like for you? *

Would you be interested in gentle 1:1 guidance? *

Yes, definitely Yes, maybe Not sure No, thank you Prefer group / self-guided

Your responses are confidential and will only be used to personalise your breathwork journey.

Discover Where You Are.
Begin Your Reset.