JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Health and Safety Survey
Your survey responses will help us determine the best setting and sequence for your Reset Workshop / Safe & Sound Protocol delivery and will be handled under HIPAA compliance policies and guidelines.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
What is your First and Last Name?
*
Your answer
What is your date of birth?
*
MM
/
DD
/
YYYY
Which conditions apply to you? Check all that apply.
*
Tinnitus (ringing in the ears)
Active or uncontrolled seizures
Controlled seizures
Severe hearing sensitivity, such as misophonia or hyperacusis
Structural ear conditions: perforated/ruptured eardrum, stapedectomy, tympanostomy tubes
Autoimmune disease, neurological disease or managing a chronic condition
Bipolar disorder, borderline personality disorder, dissociative disorder
Ongoing medical interventions during childhood
War or other local neighborhood violence exposure during childhood
Physical or sexual abuse during childhood
Was in the foster care system and/or were adopted
Active psychosis, currently taking antipsychotic meds, recent psychiatric hospital stay
History of psychosis
Active thoughts of self harm or suicidal thoughts within the last three months
Active self harm within the last three months
Dental procedures scheduled over the next few weeks or months
Currently in talk therapy with a licensed therapist or trauma-informed coach
Previous experience with talk therapy or trauma-informed coaching
Currently microdosing Psilocybin (mushrooms)
Currently doing ketamine, or other psychadelic, therapy
None of these conditions apply to me
Other:
Required
What else would you like me to know about your physical, emotional or behavioral health history?
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Retune Health.
Report Abuse
Forms
