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Neurodynamic Registration Questionnaire Form (for first timers only)

Moylan Ryan PLLC

Full Legal Name

Date of Birth

Preferred Name

Email Address

Profession / Occupation

Phone Number

Emergency Contact Name

Emergency Contact Number

Referred by

Referred by
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D
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Additional Comments

Have you ever participated in Neuro-Dynamic Breathwork before?

What brings you to want to engage in this process at this time?

Have you done any other types of expanded states of awareness / non-ordinary states of consciousness work? If so, what kind?

Are you currently in therapy and/or any other support groups?

What do you do to support your personal/psycho spiritual growth?

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

Do you give permission for photographic images and video taken during the Neuro-Dynamic Breathwork retreat/workshop that you appear in to be used for promotional purposes?