SSP Assessment
Please answer the following Questions to determine if the SSP Group Program would be a good fit for you!
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Name *
Email (if you are an SMS member, please use the email address on file with your account) *
Are you a current SMS member? *
Please respond to all questions - your responses are confidential.

IF A RESPONSE CANNOT BE ANSWERED YES/NO, PLEASE EXPLAIN IN THE FINAL 'MORE INFO' OPTION

Please note, these conditions don't necessarily rule out the SSP, so answer as honestly and accurately as possible. 
Do you have a modulation disorder (i.e. Bipolar, Borderline, Dissociative disorders, and developmental trauma)? *
Required
Do you have an ear condition such as a perforated or ruptured eardrum, stapedectomy, tympanostomy tubes, or other condition related to the structure of the ear? *
Required
Do you have a medical complexity such as an autoimmune disease, neurological disease, or other chronic condition? *
Required
Are you under the care of a psychiatrist or therapist? *
Required
Do you experience active psychosis currently, take antipsychotic medications, or have you had recent psychiatric hospitalizations? *
Required
Are you at least 30 days substance-free? This includes alcohol, psychedelics, marijuana, or other controlled substances. (this does NOT include antidepressants or prescribed medications) *
Required
Do you suffer from active and uncontrolled seizures? *
Required
Do you suffer from tinnitus or severe hearing sensitivity (i.e. misophonia or hyperacusis)? *
Required
Are you currently self-harming or experiencing suicidal ideation? *
Required
MORE INFORMATION - for any of the items above that require additional info please add it below in as much detail as possible.  *
Is there anything additional that has not been covered that you think is important when discussing nervous system regulation?  *
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