• Informed Consent, Medical Form, Emergency Contact, & Liability Waiver For Neurodynamic Breathwork Retreat

  • If you have any questions about this form please do not hesitate to ask feel free to email at themultidimensionaljourney@gmail.com

    Please read & fill out this form thoroughly & honestly for your safety & understanding.

    All your answers are held in strict confidentiality. 

  • Format: (000) 000-0000.

  • INFORMED CONSENT FOR NEURODYNAMIC BREATHWORK RETREAT

    By reading and signing this document, I acknowledge that I am voluntarily enrolling in the 1-Day Neurodynamic Breathwork Retreat. I understand that my participation is entirely optional and that I am under no obligation to participate. I voluntarily enter into this Informed Consent, Medical Information Form, Emergency Contact, and Liability Waiver for the Neurodynamic Breathwork Retreat with full understanding of its contents.

    I understand that Neurodynamic Breathwork is a personal growth and self-exploration experience intended to support self-awareness, embodiment, and quality of life. I acknowledge that Neurodynamic Breathwork is not a substitute for medical, psychological, psychiatric, or therapeutic treatment, diagnosis, or advice.

    I have been informed that this Neurodynamic Breathwork experience is rooted in transpersonal and somatic approaches, including the work of Dr. Stanislav Grof's, and is designed to support participants in accessing their own innate inner guiding intelligence. I understand that while many participants report meaningful, insightful, or transformative experiences—sometimes including challenging sensations or emotions—there is no guarantee of any specific outcome or experience.

    I understand that participation in this retreat involves guided Neurodynamic Breathwork practices, including periods of strong, connected breathing, evocative music, and verbal guidance. I acknowledge that this experience may involve intense physical sensations, emotional release, altered states of consciousness, or psychological material arising. I understand that this process may feel physically, emotionally, or mentally demanding.

    I acknowledge that I am responsible for creating and maintaining my own sense of safety throughout the retreat. I understand the importance of listening to my body, honoring my limits, and modifying or pausing my participation as needed at any time. I understand that support is available, and that I am encouraged to communicate any needs, concerns, or discomfort to the facilitators.

     

    CONTRAINDICATIONS FOR NEURODYNAMIC BREATHWORK:

    Neurodynamic Breathwork can involve dramatic experiences accompanied by strong emotional and physical release.  This workshop is not appropriate for pregnant women, person with cardiovascular problems, severe hypertension, some diagnosed psychiatric conditions, recent surgery or fractures, acute infectious illness, epilepsy or active spiritual emergency. If you have any doubt about whether you should participate, it is essential that you consult your physician or therapist as well as the workshop organizers before attending.

    Please read each contraindication carefully and mark yes or no. Adding further information at the end of the form as needed and where there are any "yes" answers.

    I have been informed to read these carefully & answer all questions honestly for my safety and if I have any questions or need clarification I can reach out to themultidimensionaljourney@gmail.com


    Do you have a past history of, have you been diagnosed with, or are you currently experiencing any of the following:

     

  • Asthma? (PLEASE NOTE: If you are diagnosed with Asthma, you will need to bring your inhaler to the retreat just in case and for safety.)*
  • Cardiovascular disease, including a history of heart attack, coronary heart disease, heart failure, aneurysms, prior cardiovascular surgery, or any current or past cardiovascular symptoms such as angina (including stable angina) or heart rhythm irregularities (arrhythmias)?*
  • High Blood Pressure?*
  • Are you taking Prescription Blood Thinning/Anti-clotting medications, such as Coumadin?*
  • Are you pregnant or could be pregnant?*
  • Epilepsy, Seizures, Strokes, Transient Ischemic Attacks (TIAs)?*
  • Recent surgery?*
  • Past or recent physical injuries, including fractures or dislocations?*
  • Present or current infectious or communicable disease?*
  • Glaucoma?*
  • Detatched Retina?*
  • Osteoporosis?*
  • Are you currently taking any type of medication? (if yes, please list below)*
  • Are you currently in therapy or involved in any type of support group?*
  • Diagnosed Psychiatric Condition(s)?*
  • Do you have a past history and/or diagnosis of Bipolar or Schizophrenia?*
  • Have you ever been psychiatrically hospitalized?*
  • Have you been hospitalized in the past 20 years for significant medical issues?*
  • Do you have any other medical or mental conditions that would impair or affect your ability to engage in any activities that involve physical and/or emotional release?*
  • Is there anything else we should be aware of regarding your overall health?*

  • PLEASE READ AND CONFIRM THE FOLLOWING:

  • MEDICAL FORM: I confirm that I have read and understood all information in the medical form, have answered all questions completely and honestly, and have not withheld any information. My general health, as far as I am aware, is good.*

  • I hereby affirm that I am in good health and able to participate in this activity. I do not have physical or mental health conditions which would impair my ability to engage in this activity or which would endanger my health during this Neurodynamic Breathwork activity, or which would cause any risk of harm to myself or other participants. I understand this Neurodynamic Breathwork retreat is not medically supervised.

    I have hereby been advised that I should talk to my physical and/or psychotherapist if I have any questions about my physical or mental ability to safely participate in this Neurodynamic Breathwork activity. If I have chosen not to obtain a physician's consent prior to my participation in Neurodynamic Breathwork, I hereby agree that I am doing so solely at my own risk.

    I understand that it is my role responsibility to participate in activities that are appropriate for the current status of my health and to modify this Neurodynamic Breathwork activity to accommodate my own needs and limitations. If I have any questions or concerns about whether or not a particular activity is appropriate to my current health status. I understand it is my responsibility to ask my doctor before I participate in such an activity.

     I agree to indemnify and hold harmless the following individuals and entities: The Multidimensional Journey LLC, its owners, managers, teachers, instructors, workshop presenters, employees, independent contractors, and staff (each, a “Released Party”). against any and all claims and expenses, including attorney fees, arising out of my participation in this Neurodynamic Breathwork activity.

     In consideration of my participation in this Neurodynamic Breathwork activity, I hereby and waive and release The Multidimensional Journey, LLC its owners, managers, teachers, instructors, workshop presenters, employees, independent contractors, and staff (each, a “Released Party”) from any and all claims, costs, liability, and expenses for any injury, loss, or damage whether known, anticipated, or unanticipated arising from my participation in Neurodynamic Breathwork

    This Waiver and Release of Liability shall be constructed broadly to provide a release and a waiver to the maximum extent and permissible under applicable law.

     I acknowledge that I have thoroughly read this Waiver and Release of Liability in its entirety and fully understand it. By signing this document, I am waiving certain rights I and/or my successors might have to bring legal action or assert a claim against The Multidimensional Journey, LLC its owners, managers, teachers, instructors, workshop presenters, employees, independent contractors, and staff (each, a “Released Party”).

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