PARTICIPANT INFORMATION:

Name of Participant: Street Address:

City: State/Providence:

Postal Code: Country:

Home Phone: Cell Phone:

E-mail Address:

Send my Welcome Packet to:
E-mail Address
Street Address
Other - please specify

 

WORKSHOP SELECTED:
(This form MUST be completed a minimum of 45 days prior to the preferred workshop)

Name of Workshop:

Preferred Workshop Dates: Alternate Workshop Dates:

 

PAYMENT INFORMATION:
A deposit of $100 must accompany this form to process your request and reserve your place in the workshop. Your FULL payment is due NO LATER than 30 days prior to the selected workshop. Please indicate how you will be making each of these payments.

Please mail personal checks or money orders to Soltura, P.O. Box 445, Gig Harbor, WA 98335.

Deposit:
 (Select a method of payment)

Workshop Fee:
(Select a method of payment)

Personal Check (payable to Soltura)
Money Order (payable to Soltura)
Credit Card (fill in form below)

Personal Check (payable to Soltura)
Money Order (payable to Soltura)
Credit Card (fill in form below)


Credit Card Information:

Name on Credit Card (exactly as it appears on card):

Bank Issuing Credit Card:

Billing Address of Credit Card:

City: State: Zip Code:

Cardholder's Telephone: Type of Card: Visa MasterCard


Card Number (no spaces or dashes):

Expiration Date: V-Code*:

* Verification Code or V-Code is a three digit number found on the back of your Visa or MasterCard credit card. The full credit card number is reprinted in the signature box and at the end of the number is the Verification Code. Soltura is required to request this number to validate that the account number is legitimate and that you have the actual credit card in your posession.

Soltura is hereby authorized to charge the above indicated payments to the stated credit card.
I ACCEPT

HOW DID YOU HEAR ABOUT SOLTURA?

Soltura Participant - If so who?
        Relationship to Participant:
Advertisement  
Therapist or Counselor  
Substance Abuse Program  
Friend or Family Member  
Referral Service
Other - Specify:

 

MEDICAL AND PERSONAL HISTORY:

Name of Participant: Date of Birth :

Current Health Status:

Are you currently under the supervision of a physician? Yes No
If so, for what purpose (Please be specific):

Do you have any current or chronic medical conditions? Yes No
If so, list them (Please be specific):

Do you have any known activity limitations? Yes No
If so, list them (Please be specific):

Dietary reqirements:
No restrictions Low salt Low sugar Special:

 

Allergies: No known allergies

(Please provide information regarding medication, food, insect bite, or other allergies: include information regarding severity and type of reaction, date of last reaction and treatment.)

Allergy
Date of Last Reaction
Severity
Describe Reaction
Treatment

 

Current Medications: No prescribed medications at this time

Name of Medication
Date Started
Diagnosis/ Reason for Medication
Potential Side Effects

 

Medical Conditions: (Have you had any of the following? Check all that apply.)

Asthma Diabetes High blood pressure Tobacco Use
Arthritis
Epilepsy/Seizure
Joint problems Ulcers
Bleeding disorder Headaches/migraines Muscle weakness Other-Specify below
Back Problems
Heart Condition
Obesity

If you checked YES to any of the items above, please provide additional information:

Condition
Date of Last Occurence
Explanation

 

Personal History: (Have you experienced any of the following? Check all that apply.)

Alcohol dependency or abuse
Mood or thought disorder
Anger management problem
Phobia or excessive fears
Anxiety problem or disorder Prescribed psychotropic medication
Depression
 Traumatic event
Diagnosed with mental disorder
Suicidal thinking/attempt
Drug dependency or abuse
Self-harm or self-abusive behavior
Eating disorder/rapid weight gain or loss
Other/ Specify below

If you checked YES to any of the items above, please provide additional information:

Condition
Date of Last Occurence
Explanation

 

Additional Health Information:

Are you currently receiving treatment for a mental or emotional issue? Yes No
If so, please explain:

Are you currently under the supervision or care of a psychiatrist or psychologist? Yes No
If so, please explain:

Please provide any other medical, emotional or behavorial health information you feel the workshop facilitator needs to know:

 

Authorization for Release of Information:

I hereby attest that the medical information provided in this document is accurate and complete and to the best of my knowledge, I am physically and emotionally capable of participating in the workshop. I further attest that if I am under treatment for any condition (physical, mental or emotional), ailment, or illness, I have consulted with my medical care provider regarding involvement in the Soltura workshop and any health complications that may potentially result. Should I require medical treatment for any reason during the workshop, I hereby authorize and consent to the release of any and all information contained herein about my medical or mental/emotional health history to any provider or facility providing medical care and to emergency transport professionals.

By clicking "I ACCEPT", I accept all the terms and conditions put forth by Soltura.

I ACCEPT I DO NOT ACCEPT