TRE Intake
Please fill out the 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 information will be kept confidential - if I feel I need some guidance from my mentor or TRE community in order to serve you better, I will seek your consent first. Know that informing me of any health issues (physical or mental) will help me to understand and guide you better.
Email address *
Full Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Emergency contact: Name and phone number. *
Your answer
Do you have any health conditions, treated or untreated, physical or otherwise? *
Your answer
If you answered YES to the above, which health conditions are you actively managing/treating, and how so? *
Your answer
What, if any, awareness/ mindfulness/ healing practices have you previously, or are you currently engaged in? *
Your answer
Have you tried TRE before? If yes, what was your experience like? *
Your answer
Do you have any physical issues that would limit or impact physical exercise? *
Your answer
Are there any areas of your body where you regularly feel tightness, tension, pain or numbness? *
Your answer
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. *
Your answer
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. *
Your answer
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