Grof® Breathwork 

Health Information Form

In order to help keep you safe during the Grof® Breathwork experience, we ask you to complete the below questionnaire about health conditions you may have. If we are concerned that a condition may contraindicate participation, one of our senior staff members will contact you by telephone to discuss our concerns. In the rare case that participation does not seem safe, your registration fee will be refunded in full. In other situations, we may ask you to modify your participation. Often, just knowing about a situation will help us work with you safely during the workshop. 

Please note that your responses to this questionnaire will be viewed only by senior staff and kept strictly confidential. Grof Legacy Training USA is a training organization and not a health care provider or other entity required to retain information in compliance with requirements of the the Health Insurance Portability and Accountability Act (HIPAA). Your responses to this questionnaire do not constitute a medical record and will be deleted after the workshop. 

Please indicate "yes" or "no" in the drop down box for various medical conditions and answer the additional questions provided. Space will be provided at the end of the form for explanations where appropriate. If you answer yes to our question about particular medical conditions, please remember to explain the condition in the box provided at the end of the listings. 

When considering this questionnaire, please note that Grof® Breathwork is intended as a personal growth experience and is not a substitute for psychotherapy or medical care. We will use our best efforts to keep you safe but ask you to take responsibility for your own well-being, including deciding whether the workshop is appropriate for you and seeking any outside assistance following the workshop that may be appropriate. If you have any doubt whether you should participate, it is essential that you consult your physician and/or therapist as well as workshop organizers before attending. 

Please be aware that breathwork can involve strong physical and emotional experiences. This workshop is not appropriate for pregnant women or for persons with cardiovascular problems such as heart attacks, cardiovascular surgery, severe hypertension, arteriosclerosis, angina pectoris, or arrhythmia. The workshop is also not appropriate for people with recent surgery or fractures, acute infectious illnesses (including Covid 19), grand-mal epilepsy, some diagnosed psychiatric conditions, or active spiritual emergency.

Please answer all questions honestly and add further information to explain any "yes" answers.

In completing this form, please enter the same email address you used to register for this event, as that email address will link your health form responses to your registration. 

If you have problems completing or submitting the form, please try signing out of the Grof Legacy Training website on your browser, then reaching the form again through the link in the email you received. For persistent issues with completing the form, please contact Jay Dufrechou at [email protected].