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?

At what age did the worst event occur?

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

Do you have Anxiety/Panic Attacks?

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?

Event 1

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. Only 1 event is required. You can be as brief or as detailed as you want here.


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

E1. Please rate to what degree the event listed above affects you

Refer to the distress scale diagram above

Event 2

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

E2. Please rate to what degree the event listed above affects you

Refer to distress scale diagram above.

Event 3

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

E3. Please rate to what degree the event listed above affects you

Refer to distress scale diagram above.

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.


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