BREATHWORK PACKAGE

BREATHWORK PACKAGE
Holotropic Breathwork

Medical Information

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 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 fracture, acute infectious disease or epilepsy. If you have any doubt about whether you should participate, consult with your physician or therapist as well as the facilitators before proceeding. The answers to the following questions are to assist your facilitators and will be kept strictly confidential. Please answer as completely as possible.

Do you have a history of, or currently suffer from any of the following: *

	Yes	No	If Yes, Explain
Cardiovascular disease, including heart attacks
High blood pressure
Severe mental illness
Recent surgery
Past or recent physical injuries, including fractures or dislocations
Recent or current infectious or communicable diseases
Glaucoma
Retinal detachment
Epilepsy
Osteoporosis
Asthma (if “Yes,” please bring your inhaler to workshop)

More Medical Information*

	Yes	No	If Yes, Explain
Are you currently pregnant?
Have you ever been hospitalized for medical reasons?
Have you ever been psychiatrically hospitalized?
Are you currently in therapy or involved in any type of support group?
Are you currently taking any type of medication?
Were there any complications at your birth? e.g. Caesarean section/Anesthesia
Is there anything else about your physical or emotional status of which we should be aware?

I hereby confirm that I have read and understood the above information and have answered all the questions completely and honestly, and have not withheld any information. My general health, as far as I’m aware, is good. I understand that body work may be performed during the Breathwork session. If I do not want body work done, or if I want body work being done to me to stop, I will say “Stop - I mean it!” in order to indicate to the facilitator what my needs are. I understand that it is my responsibility to speak up for myself, and I am able to do that.
Name*

First NameLast Name
Email
example@example.com
Date*

MonthDayYear
Date
Signature*

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CONSENT TO PHOTOGRAPH, TAKE MOTION PICTURES, VIDEO TAPE, SOUND RECORD AND/OR TELEVISION

Parent/Guardian/Client
I hereby give Hochoka and or Kimberly Clarke the right to photograph, televise, film, video tape and/or sound record the acts, appearances and utterances of ________(Client Name) and to use any descriptive words or names, including the name of ________(Client Name) in connection therewith and without limit as to time, to produce and reproduce the same or any part thereof by any method and to use said photographs, films, video tapes and/or sound recordings for any purpose which Hochoka Retreat Center and Kimberly Clarke deems proper in the interest of newspapers, television media, brochures, pamphlets, instructional material, books and clinical material, medical education, knowledge and/or research. All such photographs, films and/or sound recordings shall be the exclusive property of Hochoka Retreat Center and Kimberly Clarke and I hereby relinquish all right, title and interest therein.

With respect to the foregoing, no inducements or promises have been made to me to secure my signature to this release other than the intention of Hochoka Retreat Center and Kimberly Clarke to use or cause to be used such photographs, films and pictures for the primary purpose of promoting and aiding Hochoka Retreat Center and Kimberly Clarke and its work.
Date*

MonthDayYear
Date
Signature (Client, Parent, or Guardian)*

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In the event of an emergency, contact: *

In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of the agency, and the above cannot be reach, I authorize Hochoka and or Kimberly Clarke to:

1) Secure and retain medical treatment and transportation if needed.

2) Release participants records upon request to the authorized individual or agency involved in the medical emergency treatment.

CONSENT PLAN

This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed "'life saving" by the physician. This provision will only be invoked if the person(s) above is unable to be reached.
Consent Signature (Client, Parent or Legal Guardian)*

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Date*

MonthDayYear
Date
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Holotropic Breathwork