"*" indicates required fields Name* Email* Phone*Approximate Weight* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Occupation Employer Legal Guardian (if Applicable) Legal Guardian PhoneWhat type of session will this be?* In-Person Session Virtual Session Name of Emergency Contact* Emergency Contact Phone*Address where you are located during our sessions* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Name of referring professional / Or name of person Kathleen can thank (if applicable): Please check how you heard about Kathleen Talk or Workshop She Gave Web Search Other Teacher search - TraumaPrevention.com Teacher search - TRECanada.com How did you hear about Kathleen (other) Are you attending an upcoming event or workshop with Kathleen?* Yes No What is the location or name of the event?* Policies & ConsentCancellation Policy Your appointment time is reserved just for you. A late cancellation or a missed session leaves a hole in Kathleen’s day that could have been filled by another client. As such, she requires at least 24 hours’ notice for any cancellations or changes to your appointment. Clients who provide less than 24 hours’ notice, or miss their appointment, will be charged a cancellation fee equal to the cost of the cancelled appointment. I am aware of, and I agree to the above Cancellation Policy. Signature*Consent to Be In The Keller Method Vitality Database Consent to be in Keller Method Vitality Database. KMV deeply respects your privacy. Your address will never be shared. KMV only communicates professionally about you and your sessions, important updates about her business and pertinent information that may directly affect or interest you.I agree to be in KMV database* Yes No Medical & Health HistoryNeeds & Goals: If you wish to share, briefly explain specific needs, goals or reasons that have led you to want to learn TRE®.Physical Limitations: There are modifications for all the TRE® exercises, so most people can do TRE®. Please list and briefly explain any physical condition or limitation that limits your ability to do basic movements such as calf raises, squats and lunges. Include any joint replacements and approximate dates of these surgeries.*Additional Issues: List and briefly explain anything you think KMV should know about including illnesses, surgeries, or hospitalizations in the last year.List current prescription medications:*If there are any movement(s) that your doctor or therapist have told you NOT to do, please share what that is.Consents & Precautions Every person is unique, and each situation will be dealt with on an individual basis. TRE® Is Not Suitable If Any Of The Following Applies To You Right Now: Pregnancy Epilepsy Physical limitations (ie: broken bones) Acute concussion / whiplash Hypo/Hyperglycemia (exceptions may be made based on situation & severity) Irregular blood pressure / heart conditions (exceptions may be made based on situation & severity) Significant Surgeries healed less than six months If you indicate below that any of the conditions above apply to you at this time, Kathleen Keller will communicate with you via email or telephone prior to attending your first TRE® session.* I have read the list of precautions and agree that none of these conditions apply to me. I have read the list of precautions and I note below which of these conditions applies to me. Please note conditions below:Trauma For most people, TRE® is completely safe and highly effective. However, it is not a substitute for trauma recovery methods that are psychiatric or psychological in nature. It is not talk therapy; it is a somatic (body) release therapy. If you indicate below that any of the conditions apply to you at this time, Kathleen Keller will communicate with you via email or telephone prior to attending your first TRE® session. Complex history of trauma If under Psychiatric or Psychological care, please supply name of doctor or therapist Delicate psychological defenses Psychiatric conditions that require supervision Any concerns in this area at all If you indicate below that any of the traumas above apply to you at this time, Kathleen Keller will communicate with you via email or telephone prior to attending your first TRE® session.** I have read the information above relating to Trauma and agree that the indicators of Trauma listed do NOT apply to me at this time. I have read the information relating to Trauma and I note below which of the above indicators of Trauma DO relate to me at this time. Please note conditions below:Name of doctor or therapist Are you prone to dissociate when stressed?* Yes No I Don't Know Help me learn more about the best ways to teach you.*Please take this quiz and email the results to me at kathleen.kmv@gmail.com. I have already forwarded you the results I will take the quiz after submitting this intake form What helps to keep you grounded.* Do you have any known “triggers” that Kathleen should know about?Signature*Signature of parent or guardian (if applicable):PhoneThis field is for validation purposes and should be left unchanged.
