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 email@example.com. if you have any questions
Cardiovascular Disease, including Heart Attacks
Glaucoma or Retinal Detachment
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
Mats/Spots are limited so to secure your registration you will need to
1- email firstname.lastname@example.org 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
HOLOTROPIC BREATHWORK™ MEDICAL INFORMATION and CONSENT FORM
Emergency Contact Name
Emergency Contact Phone
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. "
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
h. Retinal detachment
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.
PRINTED NAME DATE
If you require assistance, email us at: