Date *

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

(###)

###

####

Are you currently experiencing, or have you ever experienced any of the following mental health issues?

Depression

Anxiety

Bi-polar Disorder

Phobias of any kind

Sleep Disorders

Alcohol Dependency

ADD or ADHD

Acute Stress

Self-Harm

Schizophrenia

Borderline Personality Disorder

PTSD

Eating Disorders

Agoraphobia

Grief

Obsessive Compulsive Disorder (OCD)

Trauma

Any Current Health Issues?

Heart Condition

Epilepsy

Relationship *

Single

In a Relationship

Fears and Phobias

Claustrophobia

Lifts

Water

How did you find out about TRTP?

Referral

Website

Facebook

Brochure

I understand that TRTP is a unique process which is useful for improving mental and emotional health. I also understand that for a successful outcome to occur the client is required to positively and deliberately engage in the process. A positive outcome relies not only on a quality practitioner but also on positive, proactive engagement on the part of the client. I agree to allow my de-identified data to be used in research. I agree to not change any medications without consultation with my medical practitioner. *

By selecting this checkbox, I acknowledge and agree to the statement above.