Intro Survey 2023

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Intro Survey 2023

Thank you for your interest in the iBE (Bowen and EMDR) group therapy research project for adults with relationship stress.challenges/trauma. The following information will help us get to know you and how we can best serve you.

Please start with Question 1a below.

1a. To maintain the confidentiality of your responses, please enter the last 5 digits of your driver's license number. When you complete the sets of assessment forms (Set #1 = pretest, Set #2 = last day tests, Set #3 = one month follow-up) please carefully input these 5 digits on each from, DOUBLE-CHECKING for typos. Thank you! *

1b. Our COVID Protocol: To maximize safety for our participants during COVID, we ask that any non-vaccinated persons please disclose your status to the group at the beginning on Day 1. This allows cautious persons to decide if they want to distance or mask for their own comfort. We will be outdoors on a shaded patio. IF REQUESTED IN ADVANCE: One table will have those who want to wear KN95 masks over their noses. One table will have those who prefer to be unmasked. Please indicate below whether you accept this COVID protocol, updated on 6/22/23. *

Yes

Required

2. My full name, with middle initial, is *

3. My email is *

4. My best phone is *

5. My mailing address is (house number and street, city and zip) *

6. My career is: *

7. My age is: (note, your answer will help us to seat you with other participants nearer your own age if you wish) *

8. My gender is *

8.1 What about this Comprehensive Relationship protocol interests you?

*

8.2 Are you currently in treatment? If so, please seek your therapist's guidance about adding an intensive group protocol to your healing project at this time.

Yes

I have already got my therapist's agreement.

I will seek my therapist's agreement and inform you by email.

9. In the PAST MONTH, the level of distress I've felt due to distance (from 0-10 where 10 is the most distress you can feel and 0 is no distress at all) in relationships has been: *

Required

10. In the PAST MONTH, the level of distress I've felt due to triangling such as gossip, affairs, or child focus (from 0-10 where 10 is the most distress you can feel and 0 is no distress at all) in relationships has been: *

Required

11. In the PAST MONTH, the level of distress I've felt due to overfunctioning/underfunctioning reciprocity, or co-dependency (from 0-10 where 10 is the most distress you can feel and 0 is no distress at all) in relationships has been: *

Required

12. In the PAST YEAR, the level of distress I've felt due to conflict (from 0-10 where 10 is the most distress you can feel and 0 is no distress at all) has been: *

Required

13. I have distance stressing relationships at *

a. Home

b. In my neighborhood

c. In my extended family

d. With one or more friends

e. in the nation

g. In the world

h. at work

Other:

14. I have triangles stressing relationships at *

a. Home

b. In my neighborhood

c. In my extended family

d. With one or more friends

e. In the nation

f. In the world

g. at work

Other:

15. I have Overfunctioning/Underfunctioning Reciprocity (co-dependency) stressing relationships at *

a. Home

b. In my neighborhood

c. In my extended family

d. With one or more friends

e. In the nation

f. In the world

h. at work

Other:

15. I have Conflict stressing relationships at *

a. Home

b. In my neighborhood

c. In my extended family

d. With one or more friends

e. In the nation

f. In the world

h. at work

Other:

16. Two part question: I can talk openly about my stress with supportive friends or loved ones (Part 2 is #17) *

True

False

17. Part 2: How many friends or family are you able to be open with? *

18. The statement "My support system helps me to cope" is:

Completely False

Completely True

Clear selection

19. Unresolved past distance may make new distance experiences more stressful for me. *

True

False

20. Unresolved past triangles (gossip/affairs/bullying/child focus) may make new triangling experiences more stressful for me. *

True

False

21. Unresolved past overfunctioning/underfunctioning reciprocity (like co-dependency) may make new codependency experiences more stressful for me. *

True

False

21. Unresolved past conflict may make new conflictual, critical or abusive experiences more stressful for me. *

True

False

22. I would like more skills to help me cope with distance. *

True

False

23. I would like more skills to help me cope with triangling. *

True

False

24. I would like more skills to help me cope with overfunctioning/underfunctioning reciprocity. *

True

False

24. I would like more skills to help me cope with conflict. *

True

False

25. Please check the boxes corresponding to the research study before November 16 for which you are willing to complete all the before, after, and 1 month follow-up forms (15 forms in all). Or, you are welcome to attend 1 or more paid workshops after November 16 if you want to experience more of the Comprehensive Relationship Protocol. *

Distance (FREE Research Workshop) September 29 and 30

Triangling (FREE Research Workshop) October 13 and 14

Codependency (FREE Research Workshop) November 10 and 11

Distance Workshop November 17 and 18 ($250 fee)

Triangling Workshop December 1 and 2 ($250 fee)

Codependency Workshop January 12 and 13, 2024 ($250 fee)

Conflict Workshop January 20 and 26, 2024 ($250 fee)

26. RED FLAGS regarding participating in this iBE group healing work and research at this time (check all that apply): *

I have life-threatening substance use

I am experiencing serious suicide attempts

I am experiencing any form of self-harm

I am experiencing serious assaultive behavior.

I have been diagnosed with a dissociative disorder.

None of these red flags apply to me

Required

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