MEDICAL CONTRAINDICATIONS

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  calgaryholotropicbreathwork@gmail.com. if you have any questions 

 

 

Pregnancy
Cardiovascular Disease, including Heart Attacks
Severe Hypertension
Epilepsy
Glaucoma or Retinal Detachment
Osteoporosis
Recent Surgeries
Recent Physical Injuries
Recent Infectious/Communicable Diseases
Asthma (if you have asthma, you must bring your inhaler to the workshop)
Psychiatric Hospitalization or current Mental Illness 

Once you email to register you will be sent the actual form (below is an example)  to complete and return before proceeding with your registration. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NEXT 2019 ALBERTA WORKSHOPS IN CALGARY:

Sunday November 24th

Saturday December 14th

Cost: $135.00 early bird and $185.00 up to two weeks prior 

 

REGISTRATION PROCESS: 

Mats/Spots are limited so to secure your registration you will need to 

1- email calgaryholotropicbreathwork@gmail.com expressing your desire, willingness and availability to attend

2- complete and return the consent docs (a consultation may be required if you have answered yes to any of the questions-it does not mean you are not able to attend) tht I will send when you email me

3- submit the registration fee (early bird $135 e-transfer best)

4-attend an introductory webinar -essential if this is your first Holotropic Breathwork session and you are welcome to attend again if you are experienced

The next two free introductory webinars are Wednesday November 20th at 7pm & Saturday November 16th at 9am - click on the link below to join 
https://zoom.us/j/2651237896

HOLOTROPIC BREATHWORK™ MEDICAL INFORMATION and CONSENT FORM                            
                            
Full Name                            
Address                            
City                            
Province/State Postal/Zip                            
Primary Phone                            
Emergency Contact Name                            
Emergency Contact Phone                            
Email                            
Holotropic Breathwork™ is intended as a personal growth experience and is not 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, severe mental illness, recent surgery or fractures, acute infectious illness, or epilepsy.                            
"If you have any doubt about whether you should participate, consult your physician or therapist, as well as the facilitators before attending. The answers to the following questions are to assist your facilitator and will be kept strictly confidential.  Please answer all questions completely.  "                            
                                                                                                                                                              YES    NO
1.  Do you have a history of, or currently suffer from any of the following:                            
    a.  Cardiovascular disease, including heart attacks                        
    b.  Severe mental illness                        
    g. Glaucoma                        
    h. Retinal detachment                        
    i. Epilepsy                        
    j. Osteoporosis                        
    k. Asthma (if yes, please bring your inhaler to the workshop)                        
2. Are you currently pregnant?                            
3. Have you ever been hospitalized for medical reasons in the last five years?                            
4. Have you ever been psychiatrically hospitalized?                            
5. Are you currently in therapy or involved in any type of support groups?                            
6. Are you currently taking any type of medication?                            
7. Is there anything else about your physical or emotional status we should be aware of?                                                      
If you answered "yes" to any of these questions, please explain or elaborate on a separate sheet.                            
                            
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.  My general health, as far as I am aware, is good.                              
____________________________________________________________                    ___________        
SIGNATURE                    AGE        
____________________________________________________________                    ___________        
PRINTED NAME                    DATE        
                            
 If you require assistance, email us at:  calgaryholotropicbreathwork@gmail.com                              

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