Inner Truth Registration
Name
*
First Name
Last Name
Telephone Number
E-mail
*
example@example.com
Do you have any dietary restrictions? If so please specify
*
In this retreat we will do breathwork. Several circumstances and conditions are contraindicating breathwork or need an adjustment of the methods we are using. Please answer the following questions and we might get back to discuss further how we can create a safe space for you.
Do you have any of the following conditions?
*
Pregnancy
Asthma
Severe heart disease, epilepsy, or a history of seizures
Diabetes
Acute physical injuries
None of the above
Are you currently under the care of a medical doctor?
*
Yes
No
If yes, please provide the reason including specific details, as there are contraindications with breathwork that we will discuss.
Are you currently taking any medication?
*
Yes
No
If yes, please provide more information
Prior hospitalization/surgeries. ie: what for? when?
Are you currently seeing a psychiatrist or psychologist?
*
Yes
No
If yes, please provide details of the nature for this care. For what specific purpose, for how long, the results.
Have you previously been under the care of a psychiatrist or psychologist?
*
Yes
No
If yes, please provide details of the nature for this care. For what specific purpose, for how long, the results:
Have you ever been hospitalized for psychiatric care?
*
Yes
No
If yes please provide details of the nature for this care. For what specific purpose, for how long, the results:
Are you currently taking or have been prescribed psychiatric medication?
*
Yes
No
If yes, please share which medication, for what diagnosis, for how long and the results:
Do you agree to be added to our mailing list, so you can receive updates regarding our next events?
Yes please!
No thanks!
Where will you be traveling from?
Where did you hear about this event?
Website
Facebook
Instagram
A friend
Other
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