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TRE® Module 1 Confidential Intake Form                June 29 & 30, 2024
Welcome, I look forward to working with you!
Today's date *
Name *
Date of birth *
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Email *
Physical address *
Phone number *
Occupation *
Form of payment - Link to payment page *
Brief health history (especially any major issues) *
Current health - include any physical issues that may limit exercises *
Any significant traumatic or stressful events? *
Are you currently seeing a doctor/therapist? *
Are you taking any prescribed medications? If yes, what are they? *
Have you done TRE® before? If yes, for how long? *
Anything else you think I need to know about you? *
Emergency contact name *
Their email and phone number *
Where did you hear of TRE®? *
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