Jean-Pierre Barral Symposium – Participant Submission Form

This form is to be used by Barral Institute (BI) practitioners who would like to have a client considered to participate in a demonstration session with Jean-Pierre Barral. This will take place at the Jean-Pierre Barral Symposium held on the 26th April 2016 in Sydney, Australia.

The final date for submissions is the 15th of March 2016. The selections will be made by Gail Wetzler, PT, DPT, EDO, BI-D, and will be based on the information provided below.

If your client is chosen, you will be contacted directly by BIA satellite, Shane Hill by the 4th April, 2016.

*IMPORTANT* When submitting your client for this event, please make sure your client is fully aware that they will be treated in front of an audience of potentially 120 practitioners and that this event will be filmed and the footage used for promotional purposes and practitioner education.

Jean-Pierre Barral Symposium - Patient Submission Form

Contact Details

Please ensure the below information is completed by the BI practitioner, in order for us to contact you in regards to your submissions. Especially in the event that we have any questions or queries.

Name (First, Last) *

Email Address *

Phone Number *

How many years experience do you have with the Barral methods of treatment/protocol *

Challenges you are having with this patient *

Candidate Information

Please indicate which one of the categories below, which will be covered at the symposium, that your client would qualify for, with examples of conditions for each category, for your convenience; *

Orthopedic - Lower back pain or chronic pelvic pain

Neurological - Concussion

Sports - Someone who can't quit get back into their game. Tennis, Equestrian, Running, Cycling, Football

Paediatrics - Colic baby, difficult delivery, chronic constipation, bed wetting

Geriatrics - Insomnia, chronic fatigue, vestibular problems

Cardiopulmonary - Shortness of breath, post op lung surgery, atrial fibrillation, chronic hypertension

Digestive - Gerd, gastroparesis, abdominal bloating/pain that no one has helped to date.

Name (First, Last) *

Male/Female *

Date of Birth *

Occupation

Primary Diagnosis

Medications

Treament History - Non Manual Therapy *

Treament History - With Manual Therapy *

Concerns, Questions or Other