Imagery Insights
Home
About
Services
Journal To The Self®
>
FAQ
Meditation & Mind-Body
>
Interactive Imagery
iRest® Meditation
MELT® Hand & Foot
Mindfulness Meditation
SoulCollage®
TRE® (Tension/Trauma Releasing Exercises)
Events
Booking
Contact
Shop
TRE® Intake & Waiver Forms
*
Indicates required field
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Email
*
Birth Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Birth Day
*
1
2
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Occupation
*
Emergency Contact Name
*
Phone Number
*
Relationship
*
How did you hear about Certified TRE® Provider Nancy Bunt?
*
----
Internet Search
TRE® Provider Directory on Trauma Prevention
Referral
Other
Other:
*
Have you ever had a TRE® session before?
*
----
Yes
No
If yes, for what purpose? (General wellness, stress reduction, trauma recovery, ...)
*
What do you hope to accomplish with this TRE® session or series of sessions?
*
----
Relaxation
Stress Reduction
Pain Reduction
Other - Please Explain
Other:
*
Do you have any physical limitations, injury, recent surgery or fractures, etc...?
*
----
Yes
No
If yes, please explain:
*
Have you ever been diagnosed with Epilepsy or have you ever had a seizure?
*
----
Yes
No
Are you pregnant?
*
----
Yes
No
Do you have any of the following conditions?
*
Severe anxiety or depression
Bipolar disorder
Psychoses
Severe PTSD
Schizophrenia
Fibromyalgia
Chronic Fatigue
Lyme disease
Irritable bowel
Lupus
Autoimmune disorders
Dysautomomias (MS, ALS, etc)
Severe asthma
Severe migraine
None of the above
Is there anything else your TRE® Provider should know?
*
TRE® Waiver:
Tenion and Trauma Releasing Exercises (hereafter referred to as TRE®) falls into a class of techniques and protocols referred to as Body-Based Modalities; and can be used as an aid for individuals in manifesting health and wellness for themselves. TRE® is offered to you as a self-help tool for mitigating the impact of stress in your body and in your life. Do not do TRE® if you are pregnant, have had recent surgery or fractures, or have a seizure condition such as Epilepsy. Please do not teach TRE® to others unless you have gone through the training and accrediting process to become a Certified TRE® Provider.
I, the undersigned understand and acknowledge that I am not qualified to teach or share TRE® with others from my participation.
I understand that the TRE® session or series of sessions is for the purpose of stress reduction and relaxation. I understand very clearly that a TRE® session is not a substitute for medical, or psychological diagnosis and treatment. TRE® providers do not diagnose conditions, nor do they prescribe, perform medical treatment, nor interfere with the treatment of a licensed medical professional. Nancy Bunt and A Reiki Life, LLC makes no representations about the ability of TRE® to cure any illness or ameliorate any physical or psychological conditions. I understand it is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment that I have; and/or if I feel a change in any medication or treatment regimen may be necessary.
I acknowledge that I am voluntarily participating in a TRE® session(s) with Certified TRE® Provider Nancy Bunt; assume and accept the risk of any adverse outcome that might result; and will indemnify and hold harmless Nancy Bunt and A Reiki Life, LLC for any and all injury arising from my participation.
I understand that if I use these techniques on my own, I agree to take full responsibility for my own well-being. By learning to use TRE® for myself I am releasing my right to hold Nancy Bunt and A Reiki Life, LLC from all legal, financial, and medical liability that may be incurred. I accept full responsibility for any side effect or changes in my life as a result of performing these exercises.
I have read, understood, and accept the content of this entire release form. Name/Signature:
*
Date
*
Submit
Home
About
Services
Journal To The Self®
>
FAQ
Meditation & Mind-Body
>
Interactive Imagery
iRest® Meditation
MELT® Hand & Foot
Mindfulness Meditation
SoulCollage®
TRE® (Tension/Trauma Releasing Exercises)
Events
Booking
Contact
Shop