Application

Application for Eleusis Event

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Last name

Email*

Phone

Do you currently have or have you ever been diagnosed with any of the following?

Heart disease

High blood pressure

Respiratory condition (asthma, COPD, etc.)

Epilepsy or seizure disorder

Recent surgery (within the past 6 months)

Pregnancy

Significant back or neck injury

None of the above

Please provide details if applicable.

Have you ever experienced any of the following?

Psychosis or schizophrenia

Bipolar

Panic attacks

PTSD or significant trauma

Substance dependence

Recent psychiatric hospitalization (within the last 12 months)

Suicidal thoughts within the past year

None of the above

Please tell us anything you think would help us support you safely.

Current Medications. Are you currently taking medications for mental health or physical health?

Yes

If yes, please explain

Your Intentions. What inspired you to attend?

What are you hoping to gain from this experience?

Have you previously participated in breathwork, somatic practices, meditation retreats, or similar experiences?

Yes

Informed Consent. I understand that:

This is an educational and wellness experience and is not psychotherapy or medical treatment.

I am responsible for informing the facilitators of any relevant medical or psychological conditions.

I may stop or modify my participation at any time.

Emotional and physical sensations may arise during breathwork or somatic exercises.

I understand that facilitators may recommend that I pause or discontinue participation if they believe it is in my best interest.

I agree to participate voluntarily.

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Eleusis Integrative Health

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info@eleusismedical.ca

Kelowna, BC, Canada

(250) 410-4221

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