First-time Registration

To be completed by Participants only.

REGISTRATION QUESTIONNAIRE 

Please fill in your name:

Invalid Input

Invalid Input

Please fill in your email:

Invalid Input

Can I add you to my mailing list for future events?

Yes

Invalid Input

Profession/Occupation:

Invalid Input

Please fill in your address:

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Please fill in your phone number:

Invalid Input

Emergency Contact Name and Number:

Invalid Input

Date of Birth:

Invalid Input

Referred by:

Friend

Instagram

Clubhouse

Facebook

Web search

Email

Empathic.Health

Other

Invalid Input

If other, please share details:

Invalid Input

Have you participated in breathwork before?:

Invalid Input

What brings you to want to engage in this process now?:

Invalid Input

Have you done other types of expanded states of awareness/non-ordinary consciousness work? What kinds?:

Invalid Input

Are you currently in therapy or any other support groups?:

Invalid Input

What do you do to support your personal and psychospiritual health and growth?:

Invalid Input

Do you have an questions or concerns about participating in this work?

Invalid Input

Invalid Input

Submit