SSP Remote Intake Form: Child (0-18)

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SSP Remote Delivery Rates:

The cost for SSP remote rental is $350. This gives you access to complete the SSP Core 5-hour program at home with your child, with included pre-program coaching, text support, and follow-up to ensure success. The program can be completed over time depending on you and your child’s 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.

Note to Parent:

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

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

Please note that you or another adult will need to be present with the child for all listening sessions. Co-regulation is a necessary component of SSP and the listening will not be as effective without it. I encourage you to make the SSP into a special bonding time and do a quiet activity you enjoy together and both look forward to.

If it turns out not to be the best time for your child 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 with me will help us work together to explore what will be the best way to move forward in your child’s SSP journey. 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. *
Does your child experience sound sensitivity: *
Select all that apply.
Does your child 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 use the lists of descriptors below to help you consider which your child tends more toward.

In Sympathetic hyper-arousal they might FEEL:
Select all that apply.
In sympathetic hyper-arousal your child might exhibit the following behaviors:
Select all that apply.
In dorsal vagal hypo-arousal they might FEEL:
Select all that apply.
In dorsal vagal hypo-arousal your child might exhibit the following behaviors:
Select all that apply.

Please answer the following to describe your home environment:

Will a reliable, caring adult be able to support this child's experience with the SSP and to peacefully co-regulate with them? *
Will you and your child have access to the same quiet space for the SSP listening sessions during remote delivery, and will your privacy in these sessions be respected? *
Will your child be supported to practice self-regulation between sessions and after completing SSP? Will they have access to healthy co-regulation with you or another adult? *
Are the relationships your child has with the people in their life generally supportive? *
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 child's life or those close to them which may have an impact on their 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.

Please provide details of any events happening or expected in the next few weeks or months so these can be considered. Examples are: exams, change of school or teacher, recent or upcoming move, friendship stress or trouble with peers, illness, new sibling, or recent loss of a family member or pet.

In general, how would you assess your child's and your family's current situation and experience?

Before starting your child's SSP journey, it is important you understand that this is a process you are engaging in together. It may require extra support of your child as their nervous system shifts and repatterns. 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 your child in the process and with me as your SSP provider, and understand that the SSP is not a quick fix, or a stand-alone therapy?