EXAMPLE CONSENT FORM
Before you register, please read the list of potential medical contraindications below. If any of these are issues for you, you should discuss with your medical provider and speak with a facilitator before you register.
Email firstname.lastname@example.org. if you have any questions
Once you email to register you will be sent the actual form (below is an example-not the actual form ) to complete and return before
proceeding with your registration.
Can I add you to my mailing list for future events?
EMERGENCY CONTACT NAME/NUMBER:
REFERRED BY: FRIEND: FACEBOOK: MEETUP: YELP: WEBSITE: WEBSEARCH/GOOGLE: OTHER:
HAVE YOU PARTICIPATED IN HOLOTROPIC BREATHWORK BEFORE? _______________________
WHAT IS THE DATE OF THE WORKSHOP YOU WANT TO ATTEND? __________________________
WHAT IS THE LOCATION (CITY)OF THE WORKSHOP YOU WANT TO ATTEND? _______________
If you answer 'YES’' to any of the following questions, please elaborate or explain at the bottom of this form.
Do you have a past history or currently suffer from any of the following: (Circle one)
a. Cardiovascular disease including heart attacks YES NO
b. High blood pressure YES NO
c. Diagnosed Psychiatric Condition YES NO
d. Recent surgery YES NO
e. Past or recent physical injuries including
fractures/dislocations that are not fully healed YES NO
f. Present/ current infectious or communicable diseases YES NO
g. Glaucoma YES NO
h. Retinal Detachment YES NO
i. Epilepsy (if yes, pls describe in detail on next page) YES NO
j. Asthma YES NO
k. Prior diagnosis by Medical Professional of Bipolar Disorder,
Manic Disorder or Schizophrenia? YES NO
l. Osteoporosis YES NO
Are you currently pregnant? YES NO
Have you been hospitalized for medical reasons within the last 5 years (if yes, please describe below) YES NO
Have you ever been hospitalized due to an emotional crisis (this could include severe depression, suicidal thoughts or
a psychotic episode or nervous breakdown) YES NO
Are you currently in therapy or involved in any form of support group or spiritual practice? YES NO
Are you currently taking any type of medication? YES NO
If yes, please give names and reason for taking it. ______________________________________________________________________________________
Is there anything else about your physical or emotional status we should be aware of? YES NO
Have you ever purposely injured yourself or somebody else? YES NO
On a scale going from 10 to 1 (10= very good health and 1= very poor health), could you describe how you have been feeling in the last couple of months or weeks.
Emotionally 1 2 3 4 5 6 7 8 9 10
Physically 1 2 3 4 5 6 7 8 9 10
If you answered 'YES’' to any of the above questions, please elaborate or explain at the bottom of this form.
I understand that this Holotropic Breathwork workshop is intended as a personal growth experience and should not be used as a substitute for psychotherapy. _____________(initials here) It is often used in combination with psychotherapy or other healing practices.
I understand that Holotropic Breathwork could involve dramatic experiences accompanied by strong emotional and physical release. ____________(initials here)
I understand that since my experience will be guided by my own psyche/inner healer, despite any representations made by any of your staff, or in any of your websites or other marketing materials regarding Holotropic Breathwork workshops, Calgary Holotropic Breathwork cannot guarantee any specific type of experience, result or benefit from participating in the workshop.____________(initials here)
I understand that once the workshop begins, I will not be entitled to any return or reimbursement of any of my workshop tuition or payments for any reason ____________ (initials here)
I understand that in order to get the benefits of this workshop and to be safely grounded and ready to return home, all of the components of the workshop are very important:intro talk-breathing-sitting-mandala drawing-sharing circles -end of day integration talk
I agree to keep all of what I witness, hear and see at the workshop will be held in confidence If a powerful process of a sexual nature arises I agree not to pull in or engage anyone else in my experienceI agree not to physically hurt myself, others or the surroundings and give permission to the facilitators to ensure that all people are safe I commit to stay until the workshop is over and will not leave until I have checked in with a facilitator ____________ (initials here)
Please read and sign the following statement.
I hereby confirm that I have read and understood the above information and answered all questions completely and honestly, and have not withheld any information. If there are any changes in regard to the answers on this form between now and the time of the workshop, I will notify Calgary Holotropic Breathwork in writing (email is okay) immediately.
My general health, as far as I am aware, is good.
Sign: _______________________________________________ Age: __________ Date: _______________
Please, print your name. ____________________________________________________ Phone: ____________________________
Details on any “Yes” Answers or any other information you want to share: