LIGHT and SHADOW - Movements of the MIND

Previous attendee

My New Field

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

1. Cardiovascular disease, including heart attacks, any cardiovascular surgery or any cardiovascular symptoms such as angina or arrhythmia

2. High blood pressure

3. Strokes, TIAs (transient ischemic attack), seizures, or other brain or neurological conditions?

4. Other diagnosed physical illnesses, such as Morbus Osler, Morbus Bechterew or others

5. Diagnosed psychiatric condition

6. Recent surgery

7. Past or recent physical injuries, including fractures or dislocations

8. Present or current infectious or communicable diseases?

9. Eye diseases like glaucoma or retinal detachment or similar

10. Epilepsy

11. Osteoporosis

12. Asthma (if yes, please bring your inhaler to the event)

13. Have you currently or recently had one or more of the following symptoms: fever, headache, cold and flu-like symptoms, nausea, acute respiratory problems?

b. Other information:

1. Are you currently pregnant?

2. Is there a specific traumatic reason why you want to participate?

3. Have you ever been hospitalized for significant medical issues?

4. Do you have a family history of psychiatric illness? 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? (if yes, please list below)

7. Have psychoactive substances (such as ayahuasca, DMT or others) been taken in the last four weeks? Please specify and write down below..

8. Is there anything else about your physical or emotional status (e.g. traumatic childhood experiences, accidents, other stressful events and the like) that we should be aware of?

If you answer "YES" ☑︎ to any of these questions, it is essential that you explain your answer below in the field Additional Explanatory Information.

My New Field

c. Personal experiences with altered states of consciousness (ASC) or non ordinary states of consciousness (NOSC):

1. Have you experienced Holotropic Breathwork™ before?

2. Other experiences with breathwork (rebirthing, etc.) or non-ordinary states of consciousness (NOSC) also substance-related?

Additional explanatory information * Required

PLEASE READ AND SIGN THE FOLLOWING STATEMENT: I hereby confirm that I have read and understood the above information, and have answered all questions completely and honestly, and have not withheld any information. My general health, as far as I am aware, is good and I feel healthy.

Holotropic Association Europe

LIGHT and SHADOW - Movements of the MIND

Registration Details

Medical Form

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

b. Other information:

If you answer "YES" ☑︎ to any of these questions, it is essential that you explain your answer below in the field Additional Explanatory Information.

c. Personal experiences with altered states of consciousness (ASC) or non ordinary states of consciousness (NOSC):