Questionnaire

Email *

Full Name *

City, State *

Country *

Zipcode *

Phone number *

Gender *

Birthdate *

I can receive text messages *

Which language do you speak?(partially or fluently) *

I would like to be added to the email contact list for future events of Holotropic Space NYC. *

Emergency contact name *

Emergency contact relationship to participant *

Emergency contact phone number *

How did you hear about Holotropic Breathwork? *

I have experienced Grof's Holotropic Breathwork (2.5 - 3-hr partnered framework) before. *

I have experienced other types of transpersonal or journey work. *

If yes, please elaborate.

I am currently in therapy, attending a support group or have had some form of therapeutic support in the past. *

If Yes, please elaborate.

Do you now have or have you ever had any of the following:

Cardiovascular disease, including heart attacks *

High blood pressure *

Severe mental illness *

Recent surgery *

Past or recent physical injuries, including fractures or dislocations *

Present or current infectious or communicable diseases *

Glaucoma or retinal detachment *

Epilepsy *

Osteoporosis *

Asthma (If yes, please bring your inhaler to the workshop) *

Are you currently pregnant? *

Have you ever been hospitalized for medical reasons? *

Have you ever been psychiatrically hospitalized? *

Is there anything else, physically or emotionally, we should be aware of? *

If you answered "yes" to any of the above questions, please elaborate below. (Enter "N/A" if not applicable) *

Are you currently taking any type of medication/supplements? *

Please list all medications you are currently taking for medical and / or emotional conditions. (Enter "N/A" if not applicable) *

By selecting "Yes", I am stating I have received permission from my psychiatrist / psychopharmacologist to proceed with this workshop with the current medications being prescribed, and I have scheduled a session for the week following this workshop to support my ongoing integration. *

Do you have sensitivities to any of the following? (Please check all that apply) *

PLEASE READ THE FOLLOWING STATEMENT FULLY AND SELECT "YES" AS YOUR AFFIRMATIVE SIGNATURE, IF YOU AGREE: I hereby confirm that I have read and understand the above information. I have answered all questions completely and honestly, and I have not withheld any information. My general health, as far as I am aware, is good. *

HB DISCLOSURE AND RELEASE FORM

Assumption of Risk: I understand that participating in Holotropic Breathwork can bring up issues of a highly personal nature. I also understand that this may cause unexpected and/or unpleasant emotional or physical responses. I fully understand this risk and accept the responsibility for my participation. *

Affirming Drug / Alcohol-Free Event: I understand and affirm I will not ingest any alcoholic products or plant / synthetic medicines that will impair my ability to be fully present during this workshop. I understand that by not complying with this agreement, I will be asked to leave the workshop immediately and no refund or credit for future workshop shall be granted. *

Pre-Existing Condition: I agree to disclose a pre-existing mental or physical impairment or diagnosis to the facilitators prior to attending/participating in the session or workshop. If I am working with a therapist or other health practitioner for my condition, I agree to consult with them before participating in this session or workshop, and request their consent for my participation. *

Educational Venue: I understand this workshop is never a substitute for therapy or any other form of professional consultation. I understand this session or workshop is designed for educational purposes only. *

Agreement and Release of Liability: I agree to communicate any concerns resulting from my experience in this workshop directly with the workshop facilitators to get support and guidance for how best to resolve my concerns. *

By selecting "Yes" below, I willingly agree to the preceding statements and to hold the facilitator(s), organizer(s), and all participants attending this workshop harmless from all liability. *

I agree that this disclosure and release agreement is intended to be as broad and inclusive as permitted, and that if any part of this agreement is held invalid I agree that the rest shall continue to have full legal force and effect. *

ELECTRONIC SIGNATURE CONSENT: By selecting "Yes" in this section, you are consenting to the use of your selection of "Yes" elsewhere in this form as an electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By selecting "Yes" you are waiving that right. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. Please be sure we always have a current email address in order to contact you regarding any changes, if necessary. *

IMPORTANT PAYMENT INFORMATION By selecting "Yes" I understand the workshop must be paid for in advance (see PROCEED TO PAYMENT link below this section). If cancellation occurs 1 month prior to the workshop, a full refund will be issued. Within less time a participant's fee may be applied to another workshop within a year of the registration date. For cancellations five days before the workshop, there will be no refunds or applications of funds to future workshops. PLEASE NOTE: Though rare, occasionally a participant will not have an experience with the breath. We will do everything possible to create a safe and supportive setting and to help prepare participants, however, we can only offer the opportunity to do the work - we cannot guarantee or be responsible for the individual experience of each participant. We have tried to offer the most generous refund policy possible, given our responsibility for venue, food, promotional and other costs (which are based on participant attendance). My space will only be confirmed when registration and payment fully complete. *

I hereby release and agree to hold harmless Holotropic Space from, and waive on behalf of myself, my heirs and personal representatives, any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/​or property that may be caused by any act, or failure to act, by Holotropic Space with respect to any bodily injury, illness, death, medical treatment or property damage that may arise from, or in connection to, my attendance and participation at events with Holotropic Space. *

ELECTRONIC SIGNATURE CONSENT: By selecting "Yes" in this section, you are consenting to the use of your selection of "Yes" elsewhere in this form as an electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By selecting "Yes" you are waiving that right. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. Please be sure we always have a current email address in order to contact you regarding any changes, if necessary. *