Physician’s Release Form

Due to the rigorous nature of our trainings mentally, emotionally, and physically, we as an organization, Fully Alive/Encounter Training, ask that any participant attending who has been prescribed any anti-psychotic, anti-depressant, or anti-anxiety medication in the last 5 years, consult with their physician regarding participation. Our Encounter Training is 4 days and facilitated by Master Trainers with thousands of hours of training experience, however, the training and those leading it are in no way medical professionals.

Should you have any serious concerns regarding your patient’s mental, physical, or emotional state, we ask that you would advise them as such, and/or if you have any further questions about the nature of our Encounter Training, you may contact our Director of Communication, Amy Phillips, directly at (615) 414-7942.

If you have no pressing concerns, please agree by typing in your name and basic office information below.

Physician Full Name

First Name

Last Name

Office Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Office Phone

(###)

###

####

Patient Name

First Name

Last Name

Back to Encounter Training Required Forms

Physician’s Release Form

Encounter Fund