HOLOTROPIC BREATHWORK™ MEDICAL INFORMATION FORM

Please read the following information. If you have any questions, please check with one of the facilitators.
(This form is confidential)
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Holotropic Breathwork is intended as a personal growth experience and should not be looked upon as a substitute for psychotherapy. The Breathwork process can involve a deep experience accompanied by powerful emotional and physical release as well as gentle sensations. Each session and experience are individual and unique.

This workshop is not appropriate for pregnant women, or for persons with cardiovascular problems, severe hypertension, severe mental illness, recent surgery or fractures, acute infectious illness, or epilepsy.

The answers to the following questions are to assist your facilitators and will be kept strictly confidential.

In order for us to provide support and to create the container for the HB setting for this experience, please answer the following questions and provide as much information as possible.

If you answer ‘yes’ to any of the questions below and need to provide further information use the information fields below or please send more information in a separate email]

Personal Details

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Emergency Contact

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Do you have a history of, or have you recently experienced any of the following?

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If you answered “yes” to any of these questions, please explain or elaborate below or alternatively explain in an email.

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PLEASE READ AND SIGN THE FOLLOWING STATEMENT

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. If I am submitting this form electronically, I agree that my typed name and the digital signature below shall be the binding, legal equivalent of my actual signature.

I have read, understood, and have truthfully answered the above questions.

If I have indicated a potential concern, I have provided details.

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