Eneegma Unlocked TRE® Medical Form

Type of Session/Class*

Full Name*

First NameLast Name

What is your date of birth?

Date

What is your gender?*

Marital Status*

Number of Children*

Contact Number*

Country CodePhone Number

Email Address*

example@example.com

Physical Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Medical Practitioner Full Name

First NameLast Name

Medical Practitioner Contact Number

Country CodePhone Number

Emergency Contact Person*

First NameLast Name

Emergency Contact Number*

Country CodePhone Number

Are you currently in a state to workout or do you have permission from your doctor to perform physical fitness exercises? i.e. walking, stretching, fitness training etc*

Are you currently or have you ever been under psychiatric care? If yes, for what reason?*

Are you currently taking any medication? Please provide dosage of medication, details of the health conditions and reasons for medication.*

Do you have any chronic, ongoing pain that you deal with on a regular basis? Describe what activities cause this pain and/or make it worse.*

Have you had any surgeries, hospitalization, accidents or injuries? How long ago? Do you feel you have recovered from these events?*

Have you experienced trauma e.g. Death, Accidents, Mugging, Hijacking, Sexual/Physical/Emotional/Mental Abuse, etc? Please list information you feel comfortable sharing. There will be no need to discuss these traumas in detail.*

Do you smoke or use any kind of tobacco?*

How often do you consume alcohol?*

Do any of the following conditions currently apply to you or have in the last 5 years?

Are there any other health concerns not mentioned above that are important to mention prior to performing the TRE® exercises?*

Please state your reason for embarking on the TRE® process i.e. anxiety, pain, stress, muscle tension release, etc.*

CONFIDENTIALITY CLAUSE:

Everything discussed within the confines of the time of work together shall remain confidential and shall not be divulged to any third party by your TRE® facilitator/provider. If participating in group work, no identifying material to be divulged outside of the group.

CANCELLATION CLAUSE:

I agree to give a minimum of 24 hours (one business day) cancellation notice if my participation in a TRE® Session or Class is to be canceled or changed. Failure to do so will result in full payment of the missed session, without a credit. No cash refund policy. At Eneegma’s discretion, a credit note (valid for 2 months) will be provided to the client in the event of a TRE® Session or Class cancellation within the 24 hour (one business day) notice period.

For TRE® Retreats, the standard cancellation period is 7 business days before the event. Deposits are non refundable. Each event will have a specific cancellation policy outlined at the time of booking.

Late arrival will result in reduction of TRE® session, class, retreat or workshop time while the full fee will apply.

Eneegma reserves the right to cancel an event, session or class due to low enrollment, inclement weather or other circumstances or reasons beyond our control which would make the event non-viable. If Eneegma cancels an event or session, we will do everything we reasonably can to let you know and registrants will be offered a full refund. Should circumstances arise that result in the postponement of an event, registrants will have the option to either receive a full refund or transfer registration to the same event at the new, future date.

INDEMNITY:

I undertake this treatment of my own accord and accordingly indemnify the TRE® facilitator/provider from any harm, loss or damages of any nature, or any other damages to my person or property resulting from the treatment, whether directly or indirectly.

Only clients that are the legal age of 18 years or older are allowed to sign this medical form. Any participant that is younger than the age of 18 years must have this form signed by a legal guardian or parent and be accompanied by the same to each TRE® session, class or workshop.

TEACHING EXERCISES:

If I am not a Certified TRE® Provider, I acknowledge and accept that I am NOT qualified to lead others through these exercises and that I will only use them for myself.

DATE SIGNED BY CLIENT*

Date

CLIENT FULL NAME*

First NameLast Name

CLIENT SIGNATURE: I have read and understood the above and confirm it to be true.*

TRE® PROVIDER FULL NAME

First NameLast Name

PROVIDER SIGNATURE: