Sacred Restoration Participant Application

A Somatic Experiencing Trauma Healing Intensive

at Wanderwood Farm in Nobleboro, Maine

August 27-September 3, 2024


Welcome to Sacred Restoration. Thank you for your interest in our healing intensive. This application process ensures that our program, based on the limits of our scope of practice, is an appropriate fit for your current needs. Our aim is to be able to fully support and offer you the highest level of care during the intensive. Because we are not a medical facility and we do not offer medical or psychiatric services beyond the scope of our Somatic Experiencing providers, we are taking extra care to determine that our services and limitations of care are appropriate for you at this time. If, by chance, we determine that we cannot provide appropriate support and advise that it is best for you to wait for a future intensive, we will offer you referrals and recommendations for care. Our hope will be to work with you during a future intensive.


The purpose of this trauma healing intensive is to support those who are suffering from symptoms of post traumatic stress, developmental trauma, shock trauma, chronic stress, loss, major life transitions, and professional burnout. These symptoms can include anxiety, depression, fatigue, low motivation, overwhelm, anger, self destructive behaviors, low self esteem, chronic emotional and physical pain, migraines, IBS, insomnia and more.


This program is designed to promote nervous system regulation and is not intended to diagnose, cure, or treat health conditions that need medical attention, including active addiction, psychosis, or severely destabilized mental and physical health conditions. 


We understand that trauma may lead to mental and physical health conditions, syndromes, addiction, self destructive behaviors, and more. Answering the following questionnaire as honestly and fully as possible supports our ability to offer you the best care plan.


Please set aside 20-40 minutes to answer the following questionnaire as honestly and fully as possible to ensure we are able to support you in finding the best care possible. Thank you for taking the time to apply.
* Full Name
0/50
* Preferred Name/nickname
0/50
* Phone Number
0/50
* Email
0/50
* Birthdate
0/50
* Pronouns
0/250

PROFESSIONAL AND EDUCATIONAL BACKGROUND
Level of education or professional training
0/50
* Profession/s, Vocation/s (current and recent past)
0/50
* What is your level of propfessional satisfaction?
most satisfied
least satisfied
* What is your level of life satisfaction
least satisfied
most satisfied

BACKGROUND
* How did you learn about Sacred Restoration?
0/50
* Please explain your reason for attending this program. What are your therapeutic goals?
0/250
* Describe your social or family support system and other supports you have in life
.
0/250
* Describe any community resources that you are currently accessing.
0/250


* Do you have any current medical concerns?
0/250
* Medical Conditions: please check all that apply
0/250
* Emotional/Behavioral Functioning - please check all that apply
0/250
* Basic Living Skills: Please detail if you are experiencing diffulties with activities of daily life (organization, mobility, hygeine, bathing, dressing etc)
0/250
* Do you have a history of substance use or abuse? If, yes, what is your substance of choice, amount, frequency, route? Date of last use? Age of first use?
0/250
* Have you recevied inpatient or outpatient addiction treatment?
0/250
* Are you currently in recovery? If, yes, what does recovery mean to you? What is your program?
0/250
* Do you use or have you used substances recreationally or on occasion? If yes, please explain.
0/250
* Do you use Marijuana medicinally or recreationally? If yes, please explain and include for how long, reason, amount, frequency and type.
0/250

BEHAVIORAL HEALTH TREATMENT HISTORY
* Please describe your experience with past mental health or trauma therapy. Which modalities hae you worked with and what were the outcomes? Please explain duration (when/for how long), what you liked about the experience adn what you did not like/did not find helpful.
0/250
* Have you ever been treated in an inpatient or outpatient facility? If yes, please explain.
0/250
* Have you been diagnosed with PTSD or C-PTSD? If yes, please explain.
0/250
* Are you taking medication? If yes, please list all medications, doses and frequency.
0/250
* Are you taking supplements? If yes, please list all supplements, doses and frequency.
0/250
* Have you ever worked with a Somatic Experiencing Practitioner? If yes, please describe your experience and include the name of your practitioner.
0/250
* Please list 3-5 ways that you practice self-care.
0/250
* Please list any alternative healthcare and/or touch therapy modalities that you have experienced such as Naturopathy, Acupuncture, Massage, Homeopathy, etc. and their efficacy for you.
0/250

SOCIAL HISTORY
* What is your relationship status?
* Who is living in your home? (partner, children, parents, friends, etc.)
0/250
* Please indicate important relationships with persons not in your home (family, friends, etc.)
0/250
* Have you experienced domestic violence in the home in the past or present? If yes, please explain.
0/250

DEVELOPMENTAL HISTORY
* Please describe any developmental challenges as well as any physical, psychological and/or social impacts that occured.
0/250
* Please describe what it was like growing up for you, including environmental elements like heritage, religion, who raised you, etc.
0/250
* Are there cultural considerations or context that would be helpful for the Sacred Restoration staff to know about?
0/250

ADDITIONAL INFORMATION
* Please take the time to share any additional information, comments or concerns that were not addressed in the above questions but might be relevant for your participation in this program.
0/250
* Thank you for preparing your application to participate in a Sacred Restoration Intensive. We will follow up with you within 48 hours of receiving your application. How would you like us to contact you?
Submit Application
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