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:
(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)
DATE:
YES
NO
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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.
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PRINT NAME
SIGNATURE
GENDER
I have experienced Holotropic Breathwork before:
HolotropicUKadmin:Med form ok Payment made
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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
Can you make time in your life for integrating the experience?
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?