For the retreat beginning on

Breathwork is intended as a personal growth experience and should not be looked upon as a substitute for psychotherapy. Holotropic Breathwork can involve dramatic experiences accompanied by strong emotional and physical release. This retreat is not appropriate for pregnant women, or for people with cardiovascular issues, severe hypertension, certain diagnosed psychiatric conditions, or active spiritual emergency, recent surgery or fractures, acute contagious illness, epilepsy.

If you have any doubt about whether you should or shouldn't participate, it is essential that you consult your physician or therapist, as well as the workshop organizers before attending.

The answers to the following questions are to assist your facilitators and will be kept strictly confidential. Please answer all questions as complexly as possible. If you answer "-YES-" to any of these questions, it is essential that you explain your answer on the following lines.

 

1. Do you have a past history of or currently suffer from any of the following:
Cardiovascular disease, including heart attacks -YES-no
High blood pressure -YES-no
Severe mental illness -YES-no
Recent Surgery -YES-no
Past or recent physical injuries, including fractures or dislocations -YES-no
Present or current contagious or transmissible diseases -YES-no
Glaucoma -YES-no
Retinal detachment -YES-no
Epilepsy -YES-no
Osteoporosis -YES-no
Asthma (If yes, please bring your inhaler to the workshop) -YES-no
Are you HIV positive? -YES-no
2. Are you currently pregnant? -YES-no
3. Have you ever been hospitalized for medical reasons? -YES-no
4. Have you ever been psychiatrically hospitalized? -YES-no
5. Are you currently in therapy or involved in any type of support group? -YES-no
6. Are you currently taking any type of medication? -YES-no
7. Are you addicted to any substance (e.q. alcohol, cocaine etc.)? -YES-no
8. Was there a recent tragic event in your family or among your loved ones? -YES-no
9. Do you use so-called "recreational drugs"? -YES-no
10. Do you have any experience with psychedelics? -YES-no
11. Do you have any experience with expanded state of mind? -YES-no
12. Do you have experience with Holotropic Breathwork? -YES-no
13. Is there anything else about your physical or emotional status we should be aware of? -YES-no

 

Emergency contact information

 

This medical form must be received by your workshop organizer as part of your registration. We cannot send you your confirmation letter until we receive your medical form.

PLEASE READ AND AGREE THE FOLLOWING STATEMENT: