The Power of Breathwork Retreat Application + Breathwork Health Form

Please complete this entire form for your Retreat application. Once we receive and review, we'll set up a short, 15-minute call to review and answer any additional questions.

First name*

Last name*

Birthday*

Month/Day/Year

Email*

Phone number*

Street address

City

State/Region

What interests you about this retreat?

Are you considering attending the retreat with a partner or friend? If so, please list their name.

The following section is a breathwork health form to ensure you do not have any contraindications for the Transpersonal Breathwork Journeys.

*****PLEASE NOTE: THESE ARE ENTIRELY BREATHWORK EXPERIENCES. NO PSYCHEDELIC OR ANY PSYCHOTIC SUBSTANCES WILL BE USED OR PERMITTED AT THE RETREAT. ******

Do you have a past history or currently suffer from any of the following:

Cardiovascular disease, including angina or heart attack?*

Yes

High blood pressure?*

Yes

Aneurisms?*

Yes

Mental illness or psychiatric hospitalization?*

Yes

Surgery, inpatient or outpatient?*

Yes

Recent or current infectious and/or communicable diseases?*

Yes

Glaucoma?*

Yes

Retinal detachment?*

Yes

Seizure disorder (epilepsy)?*

Yes

Osteoporosis?*

Yes

Back injuries?*

Yes

Sleep conditions (apnea, snoring, etc.)?*

Yes

Have you been advised (by a doctor or other health care provider) to restrict your physical activity in any way?*

Yes

Do you have asthma?*

Yes

If you are a woman, are you pregnant?*

Yes

Are you currently in therapy or in a support group?*

Yes

Are you currently taking any medication?*

Yes

Do you have any other physical problems?*

Yes

Is your general health good?*

Yes

Is there anything else about your physical or emotional situation that you would like us to be aware of?*

Yes

If answered, "Yes" for any question, please use this space to provide more information.*

Consent and agreement:

I understand that breathwork experiences carries risks and I take full responsibility for my decision to participate.*

Yes

I agree to follow any recommended harm reduction practices and to prioritize safety and well-being during my breathwork experiences.*

Yes

I understand that breathwork is not a substitute for medical or mental health treatment and that I should seek appropriate professional support if necessary.*

Yes

By completing this form, you acknowledge that the information provided is true and accurate to the best of your knowledge. You understand that the information shared with us is confidential and will not be shared with any third parties without your consent, except as required by law. You also understand that Prasada/The Infinite Center is not a medical professional and does not provide medical advice or treatment.*

Yes

Signature:*

Date of signature:*

Month/Day/Year