SSP Remote Intake Form: Adult

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Remote Rental Rates:

The cost for SSP remote rental is $350. This gives you access to complete the SSP Core 5-hour program at home, with included pre-program coaching, text support, and follow-up to ensure success. The program can be completed over time depending on your needs. Most complete it over a period of 2-3 weeks. Additional phone or video coaching, if needed, will be prorated. For the Core program, specific headphones are needed (inexpensive ones are fine). Headphones rental available for local clients only.

An Invitation for an Autonomic Conversation:

As we start to consider the delivery of SSP for you, it will be helpful if you could please answer the following questions as honestly as you can. Please know this form is confidential & secure.

As you will see, this is different from more traditional assessments or intake forms you may have experienced in the past. There are no rights or wrongs here. Instead, it is designed to give me more information about your current circumstances. You will see that there are two basic areas of this form for you to complete: one for you to share details about your experiences, and the other is about resources available to you.

Please note, it is necessary to have someone else present with you during each listening session. This can be a supportive partner, family member, or friend: someone you feel comfortable and safe with. Co-regulation is a necessary component of the SSP, and the listening will not be as effective without it. I encourage you to engage in a quiet, calming activity and to pause the music regularly to check in with yourself. If a supportive person is not available, I offer remote sessions over Zoom with the SSP add-on, which can be scheduled here.

If it turns out not to be the best time for you to experience SSP, or if I think there may be additional supports needed first, we will discuss this. SSP is not right for everyone, nor at every time. The details you share here will help us work together to explore what will be the best way to move forward in your SSP journey. It is usually better if you don’t spend too much time considering how to answer each question, as your initial response is often the most helpful to share. There are spaces for you to write more information that you think may be relevant or helpful for me to know.

Do you wish to rent over-the-ear headphones? (must pay shipping) Earbuds or noise cancelling headphones will not work. *
Do you experience sound sensitivity: *
Select all that apply.
Do you experience general sensory sensitivity: *
Select all that apply.
Prior completion of the SSP? *
Prior listening therapies? *

Nervous system tendency: When reacting to distressing events in our lives (becoming dysregulated or destabilized), it is normal for us to quickly move out of a restful (ventral vagal) state of social engagement and connection, and into a survival state. There are two general types of survival responses or defensive states and we usually tend toward one more than the other. The two major reactive/survival states are:

  • Activation/mobilization (sympathetic hyper-arousal), or
  • Shutdown/immobilization (parasympathetic dorsal vagal hypo-arousal)

Please note that while the following descriptors may have a negative tone, both states are important and valuable supports of the body. The purpose is not to diagnose or judge but simply discover more about your system. You may find it helpful to put a check next to the words and behaviors that typically apply to you.

In Sympathetic hyper-arousal you might FEEL:
Select all that apply.
In sympathetic hyper-arousal you might exhibit the following behaviors:
Select all that apply.
In dorsal vagal hypo-arousal you might FEEL:
Select all that apply.
In dorsal vagal hypo-arousal you might exhibit the following behaviors:
Select all that apply.
Do you have a reliable, caring person at or close to home who could support you during your SSP journey? *
Will you have access to the same quiet space for your SSP listening sessions during remote delivery, and will your privacy in these sessions be respected? *
Will you have access to a peaceful, supportive environment to practice self-regulation between sessions and after completing SSP? *
Are your relationships with the people in your life generally supportive? *
Do you have access to other nurturing and supportive resources (self-regulation)? *
Select all that apply.

Although there is always the possibility of unforeseen circumstances, it is helpful to know if there are any significant events likely to happen in your life which may have an impact on your ability to benefit from SSP. It is helpful to be aware of these in advance, if possible, so they can be factored into the timing of SSP delivery for you.

Please provide details of any events happening or expected in the next few weeks or months so these can be considered. Examples are: job stress, exams, medical procedures or operations, house move, recent bereavement, or life change.

In addition to considering your current personal circumstances, it is also helpful to reflect on the larger world and how current events and the background situation (i.e. weather, politics, crime, contagious diseases...) may be affecting you.

Before starting your SSP journey it is important you understand that this is a process you are engaging in for yourself and you will have the opportunity to learn new ways to help you stay more steady and regulated in the future. Although the listening is passive, the work to sustain the experience is intentional, and requires active engagement from you throughout.

Do you have a willingness to engage and participate fully in the process with me as your SSP provider, and understand that the SSP is not a quick fix, or a stand-alone therapy?

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