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Sacred Restoration

A Somatic Experiencing® Trauma Healing Intensive

Participant Application

2025 Dates & location in Midcoast Maine TBA


Welcome to Sacred Restoration!


Thank you for your interest in our trauma 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 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 Sacred Restoration 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 illness, emotional and physical pain, migraines, IBS, insomnia and more.


Our program is designed to promote nervous system regulation and is not intended to diagnose, cure, or treat health conditions that need medical attention or residential care, 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 complete the application. Upon receiving your submission, I will reach out to schedule a Zoom call. During this call, I can answer your questions and ensure the program aligns well with your goals.



Thank you for taking the time to apply. I look forward to meeting you!


With care,

Alexandra

Alexandra Whitney, Phd | Program Director

Somatic Experiencing Practitioner
* 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
* Profession/s, Vocation/s (current and recent past)
0/50
* What is your level of professional satisfaction?
least satisfied
most 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 personal resources or support systems 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 - please check all that apply
* Basic Living Skills: Please detail if you are experiencing difficulties with activities of daily life (organization, completing tasks, mobility, hygiene, 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 Marijuana medicinally or recreationally? If yes, please explain.
0/250

BEHAVIORAL HEALTH TREATMENT HISTORY
* Please describe your experience with past mental health or trauma therapy. Which modalities have you worked with and what were the outcomes? Please explain duration (when/for how long), what you liked about the experience and 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 or self 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 any benefits you experienced.
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 or traumas 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 our Sacred Restoration Intensive. We will follow up with you within 72 hours of receiving your application. How would you like us to contact you? If you choose email please be sure to add us to your contact list so our email (eightfoldpath501c3@gmail.com) gets to your inbox and not spam.
Submit Application
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