Confidential Health Information
We realise that the questions on this form may bring up sensitive issues. Your application is strictly confidential and your answers will help us to assess whether there is any reason why you should not participate in the Process for your own well-being.
It is not possible for us to predict any participant’s experience, or the effect of the Process on them, but if we feel that for any reason it is not appropriate for you to attend, we will try to recommend an alternative course or treatment. Your deposit would be fully refunded to you at that point. The Hoffman Institute must approve this enrolment form to confirm your place on the Hoffman Process.
The onboarding process, including the review of your application, is conducted by the Hoffman UK team. By submitting this form, you consent to your information being handled confidentially and securely, and shared as necessary between the Hoffman Institute UK and the Hoffman Institute South Africa for the purpose of assessing your suitability and supporting your participation.
In some cases we may require that you contact a Doctor or Therapist before you participate in the Process. Please ensure that you have read and fully understand and agree to our Terms & Conditions as they contain information about our cancellation policies.
It is a condition of your participation that you notify us before starting the course if there are any changes to the information you have provided.
If you have any questions please contact the UK Office on +44 (0)1903 88 99 90 or enrolment@hoffmaninstitute.co.uk.
Confidential Health Questionnaire
Has a Doctor or other practitioner ever treated you for, or told you that you have any of the below:
Allergies
Liver trouble
Shortness of breath
Chest pain
Stroke
Rheumatic fever
Heart trouble / murmur
Low / High blood pressure
Any digestive tract disorder
Gallbladder disease
Kidney disorder
Epilepsy or Dizzy spells
Convulsions
Loss of consciousness
Paralysis
Brain concussion
Severe / frequent headaches
Diabetes
An infectious disease
Joint or muscular disorder
Loss of hearing
Vision impairment
Neurodivergence / learning disability
Have you ever had any significant injuries, diseases or surgery?
Do you have any reason to believe that you are not in good health?
This course involves some vigorous bodily movement and physical activity. Do you have any physical limitations that might affect your ability to participate?
Do you have any physical issues that are aggravated by emotional stress?
6. Are you taking any prescribed medication?
7. How many hours of sleep to you typically get?
8. Have you ever suffered from insomnia/sleep disorder?
9. Are you on any sleep medication, prescribed or otherwise?
. Do you have a reading or learning disability?
Are you pregnant?
Please note: If you are pregnant we will require you to consult with your doctor and contact the office before we accept you on the Hoffman Process. If you become pregnant between completing this application and attending the course, you must consult your doctor about attending and confirm this with us.
12. How much alcohol do you drink?
Note: In order to gain the most from the Process, we ask that you refrain from alcohol and any substances which may affect your concentration or ability to access your feelings, for a minimum of two weeks before the course starts and throughout the duration of the course. In certain situations, we may recommend that you undertake therapy or treatment prior to attending. For your own safety and the safety of others it is a requirement of the Hoffman Institute that you do not bring alcohol or recreational drugs to the Process venue. If you breach or break this agreement you will be asked to leave the Process and premises.
Do you take recreational drugs?
14. Do you have, or have you ever had an eating disorder?
15. Are you in a recovery programme for any of the above?
Contact Details of your Doctor in Case of Emergency
Please provide us with contact details of your primary doctor. Please provide any background you might find useful.
16. Are you currently in therapy?
Contact Details of your Therapist
Please provide us with contact details of your therapist. We will never speak to them without your explicit permission.
17. Have you been in therapy in the past?
18. Have you ever been diagnosed with a psychological condition or psychiatric illness?
19. Have you ever been diagnosed with a psychological condition or psychiatric illness?
20. Have you ever had a ‘nervous breakdown’?
21. Have you ever suffered from or been treated for PTSD or any other traumatic response?
22. Have you ever taken any prescribed medication which is commonly used for emotional illness, anxiety or depression?
23. Do you have a history of any addictive or compulsive behaviours, e.g. work, sex, food, shopping, gambling?
24. Did either of your parents or surrogate parents suffer from a major psychiatric disorder during your childhood?
(e.g. Schizophrenia, Bipolar Disorder/Manic Depression, Major Depressive Disorder, Psychosis or Personality Disorder)
25. Have you experienced bereavement within the last 12 months?
26. Have you ever attempted suicide or self-harm?
27. Did you experience physical abuse as a child?
28. Have you ever experienced sexual abuse?
29. If you answered ‘yes’ for any of questions 25-28, what professional support have you received?
30. What would you say are your current main sources of stress? For example, current relationship / family problems, separation, divorce, work stress, illness, bereavement, addictions, major life changes.
31. What do you consider to be the most traumatic or distressing event in your life and when did it occur? Have you discussed this with anyone? Please share if and how it still affects your life today.
32. What do you hope to gain from your week on the Hoffman Process?
5. Next Steps
If you have not already spoken with one of the enrolment team, we will be in touch to arrange a convenient time to discuss the Process further.
Circa six weeks before the start of your course we will email you the pre-course work. This work is designed to teach you the essential concepts of the Hoffman Process and your responses will form much of the content of the first days of the course. We ask you to complete it comprehensively and with careful attention to each section.
Your availability for your personal Enrolment Call
Please tell us when you are free for a 45 minute phone call with a member of our enrolment team. It would be good to have two or three options. We are available Monday to Friday, between 11:15am and 7:00pm South African Time.
Agreement
Your submission of this form confirms that you understand and agree to be legally bound by our terms and conditions and also agree that the information given is true and accurate.
