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TRE® Module 1 Confidential Intake Form November 9 & 10, 2024
Welcome, I look forward to working with you!
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Today's date
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Name
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Your answer
Date of birth
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Email
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Physical address
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Phone number
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Your answer
Occupation
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Your answer
Form of payment -
Link to payment page
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PayPal
Venmo
Credit Card
Check - Made to Maria Alfaro P.O. Box 266 Soquel, CA 95073
Brief health history (especially any major issues)
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Current health - include any physical issues that may limit exercises
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Your answer
Any significant traumatic or stressful events?
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Your answer
Are you currently seeing a doctor/therapist?
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Your answer
Are you taking any prescribed medications? If yes, what are they?
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Your answer
Have you done TRE® before? If yes, for how long?
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Anything else you think I need to know about you?
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Emergency contact name
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Their email and phone number
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Your answer
Where did you hear of TRE®?
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Your answer
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