Safe & Sound Protocol (SSP) Remote Application
Individual's First Name *
Individual's Last Name: *
Individual's Date of Birth: *
Gender *
Diagnosis (if any)
Current Medications
Parent #1 Name: (if requesting for child)
Parent #2 Name: (if requesting for child)
Street Address: *
Zip: *
Email: *
Phone: *
Primary Concerns/Reason for Evaluation Request: *
Does the individual have a history any of the following: (please check all that apply .) *
If you answered "yes" to the question above, please explain the trauma history.
Have you participated in any prior therapies? (Ex: Occupational Therapy, Counseling, etc?) *
If you answered yes to the above question, please describe what type of therapy in which you/your child have participated, and the results of that therapy.
Does the individual have any of the following? Please elaborate in next section. *
If you answered yes to the question above, please elaborate on the condition(s).
Informed Consent
With SSP, there is some possibility that you will experience some gastrointestinal symptoms. This is not uncommon, but it does not happen with everyone. Some people report bowel changes or feel gassy. Please report this to your provider if it happens as there are things that can be done to help with these symptoms . There also may be an uptick in strong emotions or negative behaviors for a short time. This is not uncommon with any new type of therapy or intervention. In part, this is due to the fact that the interventions are “changing” the nervous system into a more settled state, but because this “feels” different, it can be disorienting. As time passes, your child should settle into a new, calmer state. If your child is going through a period of stress (anniversaries, beginning school, etc), participating in this project should be reconsidered until a less stressful time. In addition, with SSP, you can help by keeping extra activities and stress to a minimum for the week(s) of and week or so after the intervention. There may also be other risks that we cannot predict. If you experience any adverse effects, please contact us immediately so that we can offer support or intervention.
YOUR RIGHTS: Participation in this intervention is voluntary. You have the right for you/your child not to participate at all or to stop at any time. You have a right to complete confidentiality except in the case of reported child or elder abuse, planned harm to self or others or in the rare case that records are subpoenaed.
I understand the risks and benefits of participation and agree to allow myself/my child to participate. PROCEDURE: Once payment has been received, assessment documents will be emailed to client/caregiver. Once those completed documents are received in our office, we will complete an assessment report and set up an initial meeting (in person or online) to set up your remote account. This account will be active for 2 months from date of activation. (Exceptions made on an individual basis.) Please type your name below to indicate that you acknowledge and agree to these terms. *
Please choose the payment option you prefer. *
Gardiner Scholarship Number:
How did you hear about us? *
You are well on your way to less stress in your and/or your child's life. The next step is to pay the invoice we will email to you, then we will send you the assessment forms. We are blessed to be able to be on this journey of increased peace and harmony in your life.
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