Hypnotherapy Hong Kong, Become a Therapist, Certified Hypnotherapist

All About You Wellness Centre

TRE Indemnity Form

Name *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone Number *

Email *

Status *

If so, was your birth: *

Vaginal birth
Cesarean

Do you have any chronic, ongoing pain that you deal with on a regular basis? Describe what activities cause this pain and/or make it worse? *

Have you had any major surgeries, hospitalizations, accidents or injuries? Please specify what, when & do you believe you have physically and emotionally recovered from these events? *

Have you had any trauma? Please specify physical, emotional or other: *

Do you experience stress, anxiety, panic, fear or trauma in your life? Where and how does it manifest? What makes it worse? *

How do you currently deal with STRESS in your life? *

Do any of the following conditions currently affect you, or have in the last 5 years: (please check) *

Medications: Please advise:

Are there any other health concerns not mentioned above that are important to mention prior to performing the exercises? *

Any operations in the last three months? *

People with physical limitations such as old injuries, stiff ankles, sore knees or hips etc., who have not had an operation in the last three months, are welcome to do the exercises with caution, as each exercise can be adjusted/ modified to suit you – PLEASE INFORM YOUR TRE® PROVIDER.

Psychiatric Conditions – Please Discuss Below With Your TRE® Provider Psychiatric Conditions (with medication)
*Manic/Depressive
*Bi-polar Conditions
*Schizophrenia
*Severe/Clinical Depression
*Psychosis
*Borderline

Confidentiality
Everything discussed within the confines of the time of work together shall remain confidential and shall not be divulged to any third party by your therapist/coach. If participating in group work, no identifying material to be divulged outside of the group.

Non-identifying case material may be discussed during supervision with a designated supervisor and for exam purposes.

Cancellation Clause:
We ask that cancellations be made at least 24 hours prior to the scheduled session. Please note if cancellations are made in less than 24 hours, 50% of the session fee will be charged. If you fail to attend the session, the full fee will be charged.

Indemnity:
I undertake this treatment of my own accord and accordingly indemnify the therapist/trainer from any harm, loss or damages of any nature, whether bodily harm, trauma or any other damages to my person or property resulting from the treatment, whether directly or indirectly.

I have read the above and confirm it to be true: *

Please type your name to confirm all the information above. This will serve as your e-Signature.

Date Signed: *