TRE Intake
Please fill out this form to the best of your ability, to the extent that you feel comfortable. I can also make paper copies available if you prefer.

This survey includes questions about your physical and mental health, your current health and self-care practices, as well as any history of trauma. Know that TRE as a practice does not require us to discuss your narratives of trauma at all, and that these questions are intended to offer me both a "whole life picture" of how and who you are, and act as a screening tool in case I do not have the right scope to be YOUR provider. All of this will help me to guide and support you better.

Your information will be kept confidential. If I feel I need some guidance, I may consult with my TRE mentor or trainer, but withhold any personal identifying information like your name, location, age, etc.
Email *
Full Name *
Date of Birth *
MM
/
DD
/
YYYY
Emergency contact: Name and phone number. *
Do you have any health conditions, treated or untreated, physical or otherwise? *
If you answered YES to the above, which health conditions are you actively managing/treating, and how so? *
What, if any, awareness/ mindfulness/ healing practices have you previously, or are you currently engaged in? *
Why are you interested in TRE? What do you hopes or goals do you have for engaging with TRE? *
Have you tried TRE before? If yes, what was your experience like? *
Do you have any physical issues that would limit or impact physical exercise? *
Are there any areas of your body where you regularly feel tightness, tension, pain or numbness? *
How would you rate your general stress level these days (ex. over the past 3 months)? *
no stress whatsoever
an unbearable level of stress
How would you rate your general resilience level these days (ex. over the past 3 months)? *
Even the smallest things really hit me hard.
I can pretty much bounce back from anything given a good night of sleep.
Have you experienced any small or large traumatic events in your life? Feel welcome to give as little or as much information as you feel is relevant. *
Are you currently living with any of the following diagnoses/challenges/conditions? Check all that apply. Some of these are contraindications, some are just good for me to know so we can work smarter. *
Required
Do you have any questions right now? I can work to address these when we meet next. *
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