Urban Trauma Intensive with Dr. Maysa Akbar
February 16th-18th 2019.
Email address *
Name *
Your answer
Race/Ethnicity *
Your answer
Gender *
City *
Your answer
State *
Your answer
Phone Number *
Your answer
Do you come from or identify with a community or culture that has a history of having been affected by racism, prejudice, oppression for several generations? *
Required
Growing up, did you or your family experience poverty or uncertainty about food, clothing, or shelter? *
Required
Have you ever witnessed community violence, police brutality or ineffective policing with you or someone in your neighborhood? What did this look like for you? *
Required
Have you or a close friend or family member ever participated in gang activity or drug sale culture? *
Required
Have you ever been described by others as “angry” or “aggressive”? Do you sometimes feel angry, edgy or aggressive? *
Required
If you know, what was the experience that lead to the comment?
Your answer
Have you ever experienced depressive symptoms (isolation, loss of pleasure, feeling worthless, recurrent suicidal ideation)? If yes, explain how? *
Your answer
I have you ever tried to appear tougher so that people wouldn’t mess with me. *
Disagree
Agree
I am willing and able to trust others. *
Disagree
Agree
The weekend intensive will run from Friday 6 -9 pm, Saturday 9 am-6 pm and Sunday 9 am- 4 pm. Can you commit to the entire weekend uninterrupted? *
If you are willing to do the work, what are the changes you would like to see as a result of this weekend? *
Your answer
* Disclaimer
Your level of change is dependent upon a number of factors including your ability, dedication, self-honesty, patience, openness and willingness to be present. This weekend will NOT be a one time fix all for the challenges you are facing in life. This process is without judgement and your information if respected and confidential.

Workshop Fee applies.

A copy of your responses will be emailed to the address you provided.
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