TRE Client Info and Assessment Form

TRE Client Info and Assessment Form

Personal Details

Name:

Address:

Telephone (Home):(Work):

Mobile: Email:

Date of Birth:

Emergency Details: Telephone:

Medical Practitioner: Telephone:

Medications:

Allergies:

Medical History

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

______

______

Have you had any surgeries, hospitalizations, accidents or injuries? How long ago? Do you feel that you have recovered from these events?

______

What movements or activities are limiting?

______

______

Have you experienced any physical/emotional trauma? Details

______

______

Are you presently or have you ever been under psychiatric care?? Details

______

______

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

______

______

Please tick any of the following conditions that currently affect you, or have in the last 5 years:

Anger/RageDepressionFear/Terror

Intolerant ParanoidOverwhelmed

IrritabilityWorryAnxiety

Nervousness RestlessnessMoodiness

Panic Suicidal ThoughtsADD/ADHD

PTSD

High Blood pressure Low Blood PressureCardiac/Circulatory Problems

Blood Clots Seizures/EpilepsyHeart Attack/Stroke

Pacemaker Chest TightnessCancer/Tumours

DiabetesSugar CravingsHypo or Hyperglycaemia

Muscular Stiffness Lower Back PainPhysical Weakness

Sprains/Strains Anorexia/Bulimia Osteoporosis/Osteopenia

Pregnancy Pelvic PainSexual Difficulties

Lack of energy Sleep DifficultiesHeadaches

ME FibromyalgiaCramps/Spasms

Payment Policy

All payments are payable - Cash or EFT Payments

Emma Jane Williams

Standard Bank Constantia

Branch Code 025309

Account No. 422 286 990

24 hour policy cancellation is required. Failure to do so will result in full payment of the missed session.Payment of session is due on the day of the appointment.

Indemnity Clause

I undertake this treatment of my own accord and accordingly indemnify the therapist from any harm, loss or damages of any nature, whether bodily harm, trauma or any other damages to my person or property

Confidentiality Clause

Everything that is discussed within the confines of the time of work together shall remain confidential and shall not be divulged to any third party by Emma Jane Williams.

If participating in group work, no identifying material to be divulged outside the group.

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

I, ______

______

Client’s full name

I acknowledge and accept that I AM NOT QUALIFIED to lead others through the exercises and that I will only use them for myself.

By my signature hereto I confirm having read, understood this agreement. I further confirm that everything is TRUE.

Dated at ______on this ______day of ______20

______

Client’s SignaturePractitioner