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Worksheet

Trauma Response Resolution Intake Form

Completion of this form is required prior to being accepted as a TRR participant. Your responses to the following questions will help Kim Hallin determine whether you meet the basic intake criteria for the protocol. Your responses are strictly confidential and no one other than Kim Hallin will be able to view your saved responses. You will retain access to your saved form, which will be password protected, allowing you to edit or update your responses at any time.

Please note that your responses will not be submitted until you click SAVE WORKSHEET at the bottom of this form. 

1. ➜

Your Name:

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Your Phone Number:

3. ➜

Today's Date:

4. ➜

Have you been diagnosed with PTS(D)?

5. ➜

If yes, what was the approximate date of your diagnosis?

6. ➜

Are you currently under the care of a physician or therapist related to this diagnosis?

7. ➜

Are you taking any medications to manage your symptoms?

8. ➜

If yes, please list the medications:

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9. ➜

Sleep Patterns

What is the average number of hours you sleep per night, and the average number of awakenings you experience per night?

10. ➜

Nightmares

What is the average number of nightmares you experience per month? Any recurring ones (yes or no)?

11. ➜

PSSI-5 Score

If you have participated in a PSSI-5 (a 24-item, semi-structured clinician-administered interview used to diagnose PTSD and measure symptom severity over the past month), please share your score:

12. ➜

Traumatic Event #1

Please briefly describe the traumatic event (or phobia) you are most interested in addressing through the TRR protocol, including:

1) the nature of the event (1-5 words)

2) your age when the event occurred

3) the year the event occurred

4) the location where the event occurred (does not need to be a specific address)

5) any known triggers that prompt PTSD symptoms

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13. ➜

Traumatic Event #2

If there is second traumatic event you feel may be appropriate to address through TRR, please provide the following:

1) the nature of the event (1-5 words)

2) your age when the event occurred

3) the year the event occurred

4) the location where the event occurred (does not need to be a specific address)

5) any known triggers that prompt PTSD symptoms

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14. ➜

Traumatic Event #3

If there is third traumatic event you feel may be appropriate to address through TRR please provide the following:

1) the nature of the event (1-5 words)

2) your age when the event occurred

3) the year the event occurred

4) the location where the event occurred (does not need to be a specific address)

5) any known triggers that prompt PTSD symptoms

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