TRE® Health Background & Indemnity Form

TRE® Health Background & Indemnity Form
Name*
Email*
Date of Birth*

DayMonthYear
Do you suffer with any chronic or ongoing pain?*

NoYes
Please explain below
Please share any major surgeries, accidents or injuries you've had
Do you experience stress, anxiety, panic or fear in your life?*

NoYes
Where and how does it manifest?
What makes it worse?
How do you currently manage stress? (you can include vices as well as tools)
Have you been diagnosed with any of the below?*

Psychiatric illnessPTSDEpilepsy
What illness?
Are you taking any prescription medications?*

NoYes
What is the name and intended use?
Are you pregnant?*

NoYes
24 Hour Cancellation Policy

Should you need to cancel your session, please notify me with 24 hours notice. Failure to do so will result in you losing your session and fee. I agree to give at least 24 hours notice if I can no longer attend a session and will forfeit the session and fee if I fail to do so.
I agree to give at least 24 hours notice if I can no longer attend a session and will forfeit the session and fee if I fail to do so.*

Yes
Confidentiality Policy

Although this is not a talk therapy it is possible for feelings to arise during the process and you’ll be invited to share what comes up. Everything discussed within our work together shall remain confidential and will not be shared with any third party, unless I feel there is a risk of harm to yourself or others, in which case I have a responsibility to bring this to the attention of my TRE supervisor.
Indemnity

I undertake this treatment of my own accord and accordingly indemnify the therapist from any harm, loss or damages of any nature, whether bodily harm, trauma or any other damages to my person or property resulting from the treatment, whether directly or indirectly.
Signature*

Clear
By signing this form, I have read the above and confirm it to be true
Today's Date*

DayMonthYear
Date
Billing Address*

Country

TRE® Session Fee*

TRE® Single Session

$40.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

TRE® Health Background & Indemnity Form

24 Hour Cancellation Policy

Confidentiality Policy

Indemnity