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INSTRUCTIONS:

Please read all instructions carefully and answer the questions as accurately as possible. There are no right or wrong answers, just select the answer that best applies to your lived experiences. The following questions will ask you to identify and provide basic details regarding events you may have experienced that were stressful or traumatic.

Which type of difficult or stressful event(s) did you experience?

Exposure Event – Natural disaster, fire or explosion, transportation accident, serious accident (work, home, recreation), or toxic chemical.

Assault Event – Physical, verbal, assault with a weapon, or sexual assault.

Suffering Event – Severe human suffering, sudden violent death, accidental death, or serious injury.

Other

IMPORTANT - WHAT IS A AND HOW TO DETERMINE A SINGLE TRAUMA VS MULTIPLE TRAUMAS?

Some traumas are isolated events, like a car accident or the loss of a loved one. For some, you have to use your intuition as to how to differentiate between traumas if necessary. In implementing our therapy we have found that even though one person may have hurt someone many times in the past, our brains tend to generalize the events into one basic trauma. So please count abuse from each person as one separate trauma. You may count multiple events from one time or place in your life if they seem to group together in your imagination. Just go with what you feel.

How many different traumatic events have you experienced?

1 Event

2-3 Events

4 or more Events

At what age did the worst event occur?

0-11 12-17 18-24 25+

How would you describe your childhood?

Great

Good Overall

Ok

Overall Pretty Bad

Have you ever participated in therapy to work through the specific event(s) you have disclosed above?

Yes

No

How many sessions did you participate in?

Less than 10

Between 10-40

More than 40

2 or More Years

Not Applicable

Have you ever been prescribed medications for anxiety, depression, insomnia or PTSD?

Yes

No

Did you find this therapy improved your symptoms and/or overall mental health?

Yes

No

For a little while

Not Applicable

In this section, please individually list the traumas you have experienced in life starting with the worst trauma (the event that currently bothers you most) and ending with the trauma that affects you least. Below each trauma event, please rate to what degree the experience affects you today using the distress scale diagram. Please leave any extra events blank.

Event 1

Please list or briefly describe the worse event( what happened, who was involved).

Event 1: Please rate to what degree the event listed above affects you

Refer to the distress scale diagram above

0 1 2 3 4 5 6 7 8 9 10

Event 2

Please list or briefly describe the event( what happened, who was involved).

Event 2. Please rate to what degree the event listed above affects you

Refer to the distress scale diagram above.

0 1 2 3 4 5 6 7 8 9 10

Please tell us briefly in your own words anything further that you would like to share about the traumas you've experienced.

If you were unable to list all your traumas, please utilize this space to briefly describe and rate the ones you have not yet listed, along with any further details you wish to provide. (NOT REQUIRED, BUT WILL HELP US BETTER UNDERSTAND)

Would you like to be contacted by a team member to answer any questions about program?

Yes

No

First Name (Required)

Email (Required)

Mobile Number (Not Required, But Helpful)

INSTRUCTIONS:

Please list or briefly describe the worse event( what happened, who was involved).

Please list or briefly describe the event( what happened, who was involved).

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