When registering, please read, sign and submit this form with your payment. Each workshop is limited to 12 participants. Priority is given to the earliest postmark with full payment.Contraindications and Medical Information
CTA Workshops are intended as a personal growth experience and should not be looked upon as a substitute for psychotherapy. They can involve dramatic experiences accompanied by strong release. Contraindications mean that these workshops are not appropriate for pregnant women, persons with cardiovascular problems, severe hypertension, mental illness, recent surgery or fractures, acute infectious illness, or epilepsy. If you have any doubt about whether you should participate, consult your physician and/or therapist as well as the facilitator well before attending.
The answers to the following questions are to assist your facilitator and will be kept strictly confidential. Please answer all questions as completely as possible and return this form at your earliest convenience.
Do you have a past history or currently suffer form any of the following? YES/NO (Note: If you answer "yes" to any of these questions, please elaborate fully on the back of this form.)
- Cardiovascular disease, heart attacks, strokes, high blood pressure __
- Severe Hypertension __
- Mental Illness __
- Recent surgery __
- Physical injuries, including fractures or dislocations __
- Recent or current infectious or communicable diseases __
- Epilepsy __
- Glaucoma __
- Retinal detachment __
- Osteoporosis __
- Asthma __
- Severe allergic reactions __
- Are you currently pregnant? __
- Are you currently in therapy or involved in any type of support group __
- Are you currently taking any type of medication? __
- Is there anything else about your physical or emotional status we should know?
Signature_________________________________________________________________________________
Print Name______________________________________________________ Today's Date _______________
Address__________________________________________________________________________________
City_____________________________________________________ State __ Zip Code __________________
Home Phone _____________________ Office Phone __________________ Cell Phone ____________________
E-mail __________________________________________________ Birth Date_________________________
I need transportation from the _________Airport. Name of Airline_____________ Flight # _____ Arrives ______
I would like ride-share information: I can drive_____; I would like a ride from ______________________________
I heard about the workshops through ___________________________________________________________
Who got me to actually sign-up? _______________________________________________________________
I have been initiated by MKP___; Woman Within___. Date: __________ and Place ________________________
My therapist's name and phone are _____________________________ Phone___________________________Check interest: Level I - Healing the Father Wound® : Men East May 1-4 __; Men West July 3-6__. Women East April 24-27 ___; Women West July 24-27 ___. $650. Level II - Healing the Mother Wound®: Men East March 28-31___; Women West, April 24-27; Women East June 6-9 ___: Men West, November 21-24 __; $650. Level III - Clearing the Air™ Between Women & Men: October 21-26 ___ $995
Can't make any of the ones you have scheduled. Put me on your mailing list.Make check payable to Gordon Clay for Level I ($650) and III ($995) and send with signed forms to PO Box 1080, Brookings, OR 97415. Make check payable to Shauna Wilson Mora for Level II. ($650) and send with signed forms to PO Box 60894, Palo Alto, CA 94386. Payments using Visa/MasterCard can be made by calling 530 470-8739. Contact us here