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Trauma Center Trauma Sensitive Intake

Please complete this intake assessment.  Since TCTSY is an adjunctive treatment for complex trauma and PTSD, this assessment is needed to assess clinical fit at this time.

 

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Question 1 of 13

Have you been hospitalized for psychiatric treatment in the past six months?

A

Yes

B

No

Question 2 of 13

Are you in ongoing, individual psychotherapy?  If not, are you willing to start?

A

Yes, I am individual psychotherapy

B

No, I am not in individual psychotherapy but am willing to start or return to it.

C

No, I am not in individual psychotherapy and am not willing to engage in it.

Question 3 of 13

Please list your physical or medical conditions if you have them.  Please verify if you have been cleared for exercise and yoga by your medical team.  If you do not have any, state "none".

Question 4 of 13

Have you been given an official mental health diagnosis?  If so, please share which applies.

(Select all that apply)
A

Post-traumatic Stress Disorder

B

Anxiety (could be Generalized Anxiety Disorder, Panic Disorder, or other anxiety disorders)

C

Depression

D

Other

E

I have not been given a diagnosis or do not know.

Question 5 of 13

What symptoms are you experiencing that are currently a problem for you (e.g., nightmares/flashbacks, worrying, feeling on edge, challenges in relationships, mood problems, irritability, etc.)?  If no symptoms, type "none".

Question 6 of 13

Please share the category of the trauma you have experienced that led you to this class.  Select "Skip" if you do not feel comfortable sharing this or if it would be triggering for you to reflect on it.

 

(Select all that apply)
A

Physical Abuse

B

Sexual Abuse

C

Verbal/Emotional/Psychological Abuse

D

Neglect

E

Some other type of trauma

F

Single incident trauma (e.g., car accident, natural disaster)

G

Skip (I would rather not say)

H

I have not experienced any trauma.

Question 7 of 13

Select any substances you are actively using.  It is recommended you avoid using substances prior to class as that could impact the efficacy of treatment.

(Select all that apply)
A

Alcohol

B

Marijuana

C

Nicotine

D

Caffeine

E

Taking prescription medication not prescribed to me

F

Stimulants (e.g., Cocaine, crack, meth, etc.)

G

Psychadelics (not under the supervision of a medical or mental health provider)

H

I do not use any of these substances ever.

Question 8 of 13

Have you ever been hospitalized for psychiatric treatment?  If so, how long ago was your most recent inpatient treatment?

Question 9 of 13

Have/do you experience(d) any of the following?

A

Past suicidal ideation

B

Current suicidal ideation

C

Previous suicide attempt

D

I have never felt suicidal

Question 10 of 13

Have/do you struggle(d) with self-harm?

A

Yes

B

I did but it is no longer an issue

C

No

Question 11 of 13

What is your current living situation?

A

Live alone

B

Live with pet(s)

C

Live with roommates

D

Live with friend(s) and/or partner(s)

E

Live with family of origin

F

Live with my (created) family

G

Other

Question 12 of 13

When you are having a rough day, to whom do you turn to for support?

Question 13 of 13

Have you noticed that doing certain movements, exercises, or yoga shapes feels emotionally uncomfortable (or intolerable) for you?  Please share.

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