Learning TRE®: Intake/Disclosure form

Firstname *

Surname *

Date of Birth *

Age *

Gender *
—Please choose an option—MaleFemaleOther

Mobile *

Occupation *

City *

Country *

E-mail *

Next of kin / Emergency contact - name *

Next of kin / Emergency contact - phonenumber *

Relationshiop next of kin / Emergency contact *

Have you done TRE® before? *

If yes, please describe your experience of TRE® - how long you’ve been practicing, where and when you learned, how often you shake and any significant changes that have occurred.

What are you hoping will be different as a result of doing TRE®?

Do you currently have any medical conditions? *
YesNo

Please provide details of any heart conditions, irregular blood pressure, epilepsy, diabetes or ongoing chronic pain.

Do you experience any sensory impairment (such as vision or hearing loss or balance issues)? *
YesNo

If yes, please explain any sensory impairment:

Are you currently receiving (or have you received) any psychiatric care, therapy or counselling for anxiety, depression or any other mental health challenges? *
YesNo

Please provide details of any treatment you've received within the last 12 months.

What medications (prescription or over-the-counter), vitamins, supplements or natural remedies do you take regularly?

Have you experienced any trauma the last 24 months? *

If yes, please explain (or answer no below):

Are you pregnant?

( For women only )

If yes, how many weeks?

Irregular blood pressure (high or low) *

—Please choose an option—NoYes

Hypo or Hyperglycaemic (medications)*

—Please choose an option—NoYes

Recent surgeries *

—Please choose an option—NoYes

Irregular heart conditions (including surgery, pacemakers, and arrhythmia) *

—Please choose an option—NoYes

Vertigo/dizziness, particularly when bending over *

—Please choose an option—NoYes

Psychological conditions (such as PTSD) *

—Please choose an option—NoYes

Chronic pain (Fibromyalgia / MS) *

—Please choose an option—NoYes

Chronic fatigue (ME)*

—Please choose an option—NoYes

ADHD ADD *

—Please choose an option—NoYes

Autism*

—Please choose an option—NoYes

Addiction*

—Please choose an option—NoYes

Other and or further details from given information above (please describe below)

IMPORTANT: If you have any of the following conditions we advise that you only work with Certified TRE® Providers whose scope of practice includes experience in the treatment of these conditions. (If you have a therapist or friend you may bring them with you to learn TRE® too or support you with your TRE® in your one-to-one session.) And do not do your first few sessions of TRE® in a group.

Manic/depressive*

—Please choose an option—NoYes

Bipolar conditions*

—Please choose an option—NoYes

Schizophrenia*

—Please choose an option—NoYes

Severe depression*

—Please choose an option—NoYes

Psychosis*

—Please choose an option—NoYes

On a scale of one to ten, with ten being the most intensive, how would you evaluate the following on an average day?

Physical pain levels?*

012345678910

Emotional pain levels?*

012345678910

Current stress levels?*

012345678910

Do you have any other concerns you would like to share before attending a TRE® session?

Do you have any questions about TRE? ® prior to our scheduled session?

Write Your Signature *

Hint: Use your mousecursor with the left mousebutton pressed and write your signature in the field to confirm the disclose requirements.