2017 GHW Medical & Release Form

MEDICAL INFORMATION AND INFORMED CONSENT FORM

Holotropic Breathwork is intended as a personal growth experience and should not be looked upon as a substitute for psychotherapy.

Holotropic Breathwork can involve experiences accompanied by very strong emotional and physical release. This workshop is not appropriate for pregnant women, or for persons with severe cardiovascular problems, severe hypertension, severe mental illness or acute infectious illness. In some specific cases, this workshop would also not be appropriate in cases of recent surgery/fractures or of 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 facilitators and will be kept strictly confidential. Please answer all questions. Any Yes answers must be explained in detail (in the section designated for this, after question 10).

1. Do you have a past history or currently suffer from any of the following:

a. Cardiovascular disease (heart attack, stroke, heart valve problem, etc.) Yes |_| No |_|

b. High blood pressureYes |_| No |_|

c. Recent surgeryYes |_| No |_|

d. Past or recent physical injuries including fractures/dislocationsYes |_| No |_|

e. Present/current infectious or communicable diseasesYes |_| No |_|

f. GlaucomaYes |_| No |_|

g. Retinal DetachmentYes |_| No |_|

h. EpilepsyYes |_| No |_|

i. Asthma (If yes, please bring your inhaler to the workshop)Yes |_| No |_|

j. OsteoporosisYes |_| No |_|

k. If you are a woman, are you currently pregnant?N/A |_|Yes |_| No |_|

2. Have you been hospitalized for medical reasons?Yes |_| No |_|

3. Have you ever been hospitalized due to an emotional crisis?Yes |_| No |_|

4. Have you ever been diagnosed with a psychiatric condition, such as Bipolar Disorder,

Manic Disorder or SchizophreniaYes |_| No |_|

5. Have you ever purposely injured yourself or somebody else?Yes |_| No |_|

6. Are you currently in therapy or involved in any form of support group or practice? Yes |_| No |_|

7. Are you currently taking any type of medication? Yes |_| No |_|

8. Do you know about any complication that occurred during your birth process?Yes |_| No |_|

9. From a scale going from 1 to 10 (1= very poor and 10= very good), could you describe how you have been feeling in the last couple of months or weeks?

Emotionally1 |_|2 |_|3 |_|4 |_|5 |_|6 |_|7 |_|8 |_|9 |_|10 |_|

Physically1 |_|2 |_|3 |_|4 |_|5 |_|6 |_|7 |_|8 |_|9 |_|10 |_|

10. Is there anything else about your physical or emotional status we should be aware off?Yes |_| No |_|

If you answered 'yes' to any of the above questions, please elaborate and explain in detail (description, dates, treatment, times, etc.) 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 regards to the answers on this form between now and the time of the workshop, I will notify the organizers in writing immediately.

My general health, as far as I am aware, is good.

The submission of this form electronically constitutes a signature.

Participants Signature: Date: Participants Printed Name:

Date of the workshop that you are registering for:

Grof Holotropic Work San Diego

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INFORMED CONSENT

General nature of Holotropic Breathwork:

The Holotropic Breathwork workshop begins on Friday with group introductions, discussion about the theory and practical details, and an opportunity for questions. During this introductory talk, the participants will be guided in the process of choosing partners for the actual breathwork on Saturday. One member of each pair will do the breathwork while their partner acts as sitter (In the second session, the roles are reversed.)

At the start of the Holotropic Breathwork sessions on Saturday, the breathers lie on a mat, are talked through a brief meditation and then asked to breathe faster and more deeply than usual. At that point, evocative music begins and continues for the next approximately two and a half hours.

The breather is asked simply to remain open to whatever kinds of experiences present themselves. This can include, but is not limited to, deeply restful or ecstatic states, vivid reliving of past experiences, release of energy from the body, strong emotions (either pleasant or difficult), spiritual experiences or experiences that seem to come from the collective unconscious or other transpersonal areas of consciousness.

The sitter's role is to sit next to the breather, and respond to any needs such as water, blankets, help getting up to walk to the bathroom, etc. On occasion, if the breather requests it and the sitter is comfortable doing so, the sitter may provide physical touch such as applying pressure to tight or uncomfortable areas of the body or holding the breathers hand.

During the breathing process, the facilitators circulate in the room and are available to individual breathers when needed. Sometimes no intervention is required except a brief conversation with the breather toward the end of the session to discuss their physical and emotional state and help them decide whether or not they're ready to get up. On other occasions, especially if a breather is experiencing difficult emotions or physical discomfort, a facilitator may intervene with permission. This can involve some limited conversation and often, if the breather has agreed to it, some energy release work or other support.

Contraindications: Holotropic Breathwork has certain medical and psychological contraindications, including high blood pressure and other cardiovascular conditions, glaucoma, surgeries or recent injuries, pregnancy, or recent psychiatric hospitalization. Sometimes Holotropic Breathwork can involve strenuous physical exertion by participants which can cause such things as increased blood pressure or muscular/skeletal injuries. Holotropic Breathwork also may activate intense emotional experiences which can continue beyond the time of the breathwork session and for which post-session therapy or other support is recommended. For the safety of participants, facilitators reserve the right to not allow a person to continue participation and to cancel registration based on contraindications including, but not limited to, those listed.

Alternative treatments: There are many methods of individual and group therapy as well as many spiritual practices which, alone or in combination, may be good alternatives to Holotropic Breathwork. Holotropic Breathwork is not a substitute for psychotherapy or medications.

I, [participant name], want to participate in the workshop offered.

I understand that this Holotropic Breathwork workshop is intended as a personal growth experience and should not be used as a substitute for psychotherapy and that the facilitators are not acting as psychotherapists.Your initials here:

I understand that Holotropic Breathwork could involve dramatic experiences accompanied by strong emotional and physical release, which can continue beyond the time of the breathwork session and for which post-session therapy or other support is recommended.Your initials here:

I understand that since my experience will be guided by my own psyche/inner healer, despite any representations made by any of the staff, or in any websites or other marketing materials regarding Holotropic Breathwork workshops, the organizers cannot guarantee any specific type of experience, result or benefit from participating in the workshop.Your initials here:

I understand that once the workshop begins and if I cancel my registration within 72 hours of the workshop, I will not be entitled to any return or reimbursement of any of my workshop tuition for any reasonYour initials here:

In order to get the benefits of this workshop and to be safely grounded and ready to return home, all of the various pieces of the workshop (intro talk on Friday evening, and breathing, sitting, mandala drawing, sharing group, integration talk on Saturday) are very important. Because of this and also because I may have an expanded state of awareness experience, I understand that in order to be accepted to attend this workshop, I agree to stay for the entire event. If, despite the above, I still decide to leave the workshop without completing it, I understand and agree that (1) I will notify a Facilitator before leaving to receive any of the Facilitators instructions/directions which could minimize the consequences of early departure; and (2) in accordance with the "Release, Waiver, and Indemnity of Liability Agreement", I will be accepting full responsibility for any consequences of leaving early and release and waive any and all claims which I might have against the organizers in connection with my early departure.Your initials here:

I acknowledge that consuming alcohol or mind-altering substances prior to or during the workshop is not permitted. Facilitators can refuse admission to any participant they feel might be negatively affected by substances. Your initials here:

I have read and understand all of the previous information in this document regarding risks and agree to undertake these. I understand and agree that I am attending the sessions at the discretion of Facilitators and I can be dismissed from the sessions at any time.Your initials here:

The submission of this form electronically constitutes a signature.

Participants Signature: Date: