You are on page 1of 3

Workshop Registration Form

Thank you for your interest in attending one of our Holotropic Breathwork workshops. To
register for a particular workshop please tell us which one what you would like to attend:

Date of the workshop I would like to attend: .............................................


If you have not previously breathed with Holotropicuk please also complete the General
Information sheet for all breathers new to HolotropicUK (page 3 below).
YOUR NAME: (please print)...............
ADDRESS:
EMAIL ADDRESS:...
TELEPHONE: (H)

(M)..

Early bird registration rates are available if you register and pay in full 6
weeks before the date of the workshop:
Residential workshops 2015:
400 in a shared twin en-suite room in the main house
460 single occupancy of a twin room in main house (limited availability)

One-day workshops - 120


Normal workshop rates 2015 are:
Residential workshops:
440 in a shared twin en-suite room in the main house
500 single occupancy of a twin room in the main house (limited availability)

One-day workshops - 140


Diet Information: I eat meat ...
I am a vegetarian.
Please note: A fridge is available for personal use should you have specific diet requirements.
Please post this Registration Form to HolotropicUK at: 3 Grove Farm Cottages, Grove Lane,
Chesham, Bucks HP5 3QQ, UK or send electronically to: Breathworks @ holotropicuk.co.uk.
Payment can be made either by cheque made out to: HolotropicUK Ltd at the above address or
by on-line transfer, (details on request). Please help us track your payment by using your
name as the reference when you make on-line transactions. We can also accept payment by
PayPal and will send you an Invoice if this is your preferred method of payment.
AMOUNT ENCLOSED/TRANSFERRED:
Any Comments: ................................................................................................................................
SIGNATURE:

DATE:

Holotropic Breathwork Participant Information & Agreement


This INFORMATION AND AGREEMENT Form must be received by HOLOTROPICUK as part of your
registration. We cannot send your confirmation letter until weve received this 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. It is not appropriate for pregnant women, or for persons with
cardiovascular problems, severe hypertension, some diagnosed psychiatric conditions, recent surgery or
fractures, acute infectious illness or 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 Holotropicuk before attending.
The answers to the following questions are to assist the workshop facilitators and will be kept strictly
confidential. Please answer all questions as completely as possible.
MEDICAL BACKGROUND
1. Do you have a past or current history of any of the following:
A) Cardiovascular disease, including heart attacks and cardiovascular surgery
B) High blood pressure
C) Diagnosed psychiatric condition
D) Recent surgery
E) Past or recent physical injuries, including fractures or dislocations
F) Present or current infectious or communicable diseases
G) Glaucoma
H) Retinal detachment
I) Epilepsy
J) Osteoporosis
K) Asthma (If yes, please bring your inhaler to the workshop)
2. Are you currently pregnant?
3. Have you been hospitalized in the past 20 years for significant medical issues?
4. Have you ever been psychiatrically hospitalized?
5. Are you currently in therapy or involved in any type of support group?
6. Are you currently taking any type of medication? Describe on back.
7. Is there anything else about your physical or emotional status we should
be aware of?

YES

NO

____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____

____
___
____
____
____
____
____
____
____
____
____
____
____
____
____
____

____

____

If you answer "yes" to any of these questions, it is essential that


you explain your answer on the back or on an attached page.
My General health is Good - Yes / No (please specify):....
Emergency contact information: name __________________________ phone __________________

AGREEMENT:
I hereby confirm that I have read and understood the above information, and have answered all
the questions accurately and completely and have not withheld any information. I am aware that
emotional issues may be evoked during breathwork and that this workshop is not therapy. I
understand that it is my responsibility to seek out professional emotional support if needed. In
addition, I am aware that the breathwork process may invite physically stressful movement and
that it is my responsibility to evaluate whether or not to engage in such movement based on my
physical condition. My participation in this workshop is purely voluntary. I elect to participate in
spite of the above-mentioned risks.
____________________ ___________________
_________
PRINT NAME
SIGNATURE
GENDER
I have experienced Holotropic Breathwork before:
HolotropicUKadmin:Med form ok Payment made

______ _____________
AGE
DATE
YES or NO
Conf letter sent

GENERAL INFORMATION
This is required please, for all breathers new to HolotropicUK
Please use additional pages if necessary

Why do you want to come to this workshop?

Have you previous knowledge or experience of Holotropic Breathwork?

What is your understanding of the process?

How did you hear about Holotropic Breathwork?

Can you make time in your life for integrating the experience?

Who will support you in the integration process?

Are you currently in therapy? If so, what kind?

Does your therapist know about this work and support your participation?

Have you experienced recent trauma, e.g. the death of a close relative?

Describe any other significant trauma in your life, for example, illness, accidents, or abuse.

What do you know about your birth? Were there complications such as breach, caesarian etc?

Is there anything else you would like us to know about?