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 workshop is not appropriate for pregnant women, or for persons with cardiovascular problems, severe hypertension, some diagnosed psychiatric conditions (Bi-polar, Schizophrenia) recent surgery or fractures, acute infectious illness or epilepsy, or active spiritual emergency. If you have any doubt about whether you should 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 completely as possible – where you answer ‘yes’, please add further information at the end/on the back:
| Do you have a past history of, have you been diagnosed with, or are you currently experiencing any of the following: | Yes | No |
| Cardiovascular disease, including heart attacks, any cardiovascular surgery and any cardiovascular symptoms such as angina or arrhythmia | ||
| High blood pressure Strokes, TIAs, seizures, or other brain or neurological conditions | ||
| Diagnosed psychiatric condition | ||
| Recent surgery | ||
| Past or recent physical injuries, including fractures or dislocations | ||
| Present or current infectious or communicable diseases | ||
| Glaucoma | ||
| Retinal detachment | ||
| Epilepsy | ||
| Osteoporosis | ||
| Asthma (if yes, please bring your inhaler to the workshop) | ||
| Other information: | ||
| Are you currently pregnant? | ||
| Have you been hospitalized in the past 20 years for significant medical issues? | ||
| Have you ever been psychiatrically hospitalized? | ||
| Are you currently in therapy or involved in any type of support group? | ||
| Are you currently taking any type of medication? (if yes, please list) | ||
| Is there anything else about your physical or emotional status we should be aware of? |
Emergency contact information:
Name __________________________________________ phone ________________________
PLEASE READ AND SIGN THE FOLLOWING:
I hereby confirm that I have read and understood the above information, and have answered all questions completely and honestly, and have not withheld any information. My general health, as far as I am aware, is good.
______________________________________ ____________ _____ _______
Name & Signature Date Age Gender
email:- __________________________________________
I have experienced Holotropic Breathwork before: Yes / No
