Somatic Research Form | elementalAdvanced MT

Thank you for your participation in this survey for our research purposes! Your responses will be used as data only and remain anonymous.

Today's Date Is

First name

Last name

Email

Phone

Birthday

Ethnicity (choose all that apply)

Do you identify as LGBTQ or non-binary?

Yes

No

Please check all that apply:

I am a recipient of somatic therapy to address the effects of trauma on my body

I am a State licensed practitioner of somatic therapies

I am an unlicensed practitioner of somatic therapies

How many years have you been practicing and/or receiving this type of therapy?

Please check all of the types of somatic therapies you have participated in that were related to addressing your concerns of the effects of complex trauma or chronic stress on your body and mind.

When you received this therapy did you feel a sense of safety and support before the experience.

Yes

No

During the therapy did you feel a sense of safety and support.

Yes

No

After the experience did you feel a sense of safety and support with the therapist.

Yes

No

Would you describe your overall experience with somatic therapies as:

Positive

Negative

Feel free to describe the specific reasoning for this general assessment.

If you participated in multiple types of therapies, please describe which you think was/were the most positive and/or negative, and why:

Before you participated in a somatic therapy were you given (if recipient), or did you give your client (practitioner), a prescreening questionnaire or intake that specifically assessed for history of complex trauma or chronic stress.

Yes

No

Please elaborate on what kind of assessment was given. For example, a common assessment is the "Adverse Childhood Experiences" questionnaire, but it could have been anything else that assessed the potential levels of resilience within the nervous system.

Please list any comments or concerns that you may have that could improve outcomes for trauma inspired practices in the future.

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Donations toward our research work are very much appreciated! Research and writing are not currently funded, and done totally on a voluntary basis. Donations are tax deductible through the 501(c)3, www.gratitudehealingartsfoundation.org. Be Blessed!

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