Home
About
Services
Imagery & Meditation
>
Interactive Imagery
iRest®
Mindfulness Meditation
SoulCollage®
Journal Writing
Reiki
>
Distance Reiki Sessions
Reiki Consulting
Somatic
>
MELT® Hand & Foot
TRE® (Tension/Trauma Releasing Exercises)
Online Courses
Podcast
Personalized Group Sessions
Events
Booking
Contact
Store
TRE Intake & Waiver
*
Indicates required field
Name
*
First
Last
Email
*
Phone Number
*
Birthday (month)
*
Select One
January
February
March
April
May
June
July
August
September
October
November
December
Birthday (day)
*
Select One
1
2
3
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 Nancy Bunt?
*
Have you 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?
*
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? (Check all that apply):
*
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 these
Is there anything else you think your TRE Provider should know about?
*
TRE® Waiver
Tension and Trauma Releasing Exercises (hereafter referred to as TRE®) falls into a class of techniques and protocols referred to as Body-Based Wellness Practices; 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 in this session or series of sessions.
I understand that the TRE® session or series of sessions is for the purpose of stress reduction, and supporting general wellness. 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. Certified TRE® Provider - Nancy Bunt, and Nancy Bunt, 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 or series of sessions 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 Nancy Bunt, 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 personal use, I agree to release Nancy Bunt and Nancy Bunt, LLC from all legal, financial, or medical liability that may arise. I fully accept responsibility for any effects or changes that may occur in my body and life as a result of using the TRE® techniques.
I have read, understood, and accept the content of this entire release form.
*
Yes
Signature:
*
Date:
*
Submit
Home
About
Services
Imagery & Meditation
>
Interactive Imagery
iRest®
Mindfulness Meditation
SoulCollage®
Journal Writing
Reiki
>
Distance Reiki Sessions
Reiki Consulting
Somatic
>
MELT® Hand & Foot
TRE® (Tension/Trauma Releasing Exercises)
Online Courses
Podcast
Personalized Group Sessions
Events
Booking
Contact
Store