Registration for Exeter, UK, Workshop, April 2020

    Registration and Health Check Information for Breathwork Participants

    Health Cautions: The Breathwork experience can involve dramatic experiences accompanied by powerful emotional and physical release. Pregnancy, cardiovascular disease, severe hypertension, a family history of aneurisms, recent surgery or fractures, infectious disease, seizure disorder, or certain psychiatric conditions are contraindications. So we can advise you properly about this, please answer the following questions. Your personal data are protected; we will keep all your answers confidential. Your information will help us create a safe setting for this experience. If you have any questions before registering, please contact us:

    Holotropic Breathwork is deeply experiential and may involve intense and energetic emotional release. Workshops do not substitute for psychotherapy, but can significantly deepen and enhance psychotherapy and other healing and personal growth efforts.

    Workshop Date (required)

    Full Name (required)

    Date of Birth (required)

    Email Address (required)

    Telephone Number (required in international format.)

    Mailing Address (required)

    Country (required)

    Use the "Further Information" field (#10) of this form to give details regarding any "yes" answers.

    1. Do you have any of the following (required):
    Cardiovascular disease, including angina or heart attack   
    High blood pressure   
    A family history of aneurysms   
    A personal history of mental illness or psychiatric hospitalization   
    Surgery, inpatient or outpatient   
    Past or recent significant physical injuries   
    Recent or current infectious or communicable diseases   
    Retinal detachment   
    Seizure disorder (epilepsy)   
    Back problems   
    Sleep problems (apnea, snoring, etc.)   

    2. Have you been advised (by a doctor or other health care provider) to restrict your physical activity in any way?   

    3. Do you have asthma? (If you do, please bring your inhaler and call our attention to it at the workshop.)   

    4. Are you pregnant?   

    5. Are you currently in therapy or in a support group?   

    6. Are you currently taking any medication?   

    7. Do you have any other physical problems?   

    8. Is your general health good?   

    9. Is there anything else about your physical or emotional situation that you would like us to be aware of?   

    10. Further Information. Please explain any "yes" answers to the the above questions (except for #8).

    11. Specify any special dietary needs for your meals here (vegetarian, gluten-free, allergies, or any other).

    12. About you: please write a few sentences about yourself so we can get to know you a bit before the workshop.

    13. Have you experienced Holotropic Breathwork before?   

    14. Emergency Contact name, phone number in international format, relationship to you.

    PLEASE READ AND CONFIRM THE FOLLOWING STATEMENT: I hereby confirm that I have read and understood the above questions and have answered them all fully. My general health, as far as I am aware, is good.

    For additional information about any of our events, please contact us:
    Elizabeth Gibson, 128 Solar Park, Pawlet, Vermont 05761, USA

    Thanks for your interest in our workshops!

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    Mandala by Beth Piper