As a participant in the Katabasis Institute program, I am registering for the Holotropic Breathing workshop (June 26-29, 2025)

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First and last name *

First Name

Last Name

Address *

Phone *

Email *

I would like to share a room with someone

Special needs *

• I have special dietary needs
• I need help organizing transportation
• None of the above

Details of special needs

Are you currently or have you in the past suffered from any of the following diseases: *

• a) Cardiovascular diseases, including heart attack or heart and blood vessel surgery?
• b) High blood pressure
• c) Diagnosed psychiatric condition or problems
• d) Recent surgeries
• e) Past or recent injuries, fractures, dislocations
• f) Past or present communicable diseases
• g) Glaucoma (increased eye pressure)
• h) Retinal detachment (ablatio retinae)
• i) Epilepsy
• j) Osteoporosis
• k) Asthma (if yes, please bring your inhaler to the workshop)
• None of the above

Other important health information (check if applicable) *

• Are you pregnant?
• Have you been hospitalized for medical reasons in the past 20 years?
• Have you ever been hospitalized for psychiatric reasons?
• Are you currently experiencing a mental crisis?
• Are you currently attending individual or group psychotherapy?
• Are you currently taking any medications? (please specify which)
• Is there anything else important regarding your psychophysical condition that you would like to inform us about so that we can safely support you at the workshop?
• None of the above

If your answer to any of the above questions is yes, please make sure to provide us with the details here.

Additional explanations of positive answers from the medical questionnaire:

emergency: of experience

Please provide the name of a close person to contact in case of emergency: *

Phone number of close person to contact *

GenderMaleFemale

Age *

Date *

I have experience with Holotropic Breathing *

• YES
• NO

Signature *

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