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.

First Name
Mobile Number

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?

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

At what age did your first event occur?

Do you have Anxiety/Panic Attacks?

What was the longest amount of time you were exposed to a single stressful event?

How would you describe your childhood?

The following questions ask about your previous experiences with therapy or other mental health services. If the subsequent questions do not apply to you, please select "Not Applicable" and move forward.

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

How many sessions did you participate in?

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

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

Please tell us briefly in your own words what traumas you've been through?

Please limit your response to 600 characters or less.

Of the traumas you shared, which bothers you the most?


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