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"No mud no lotus"

~ Thich Nhat Hanh

Making Our Way Home

A Somatic Experiencing® Trauma Healing Program

Participant Application



Location: Some Space | 30 Chestnut Street, Camden, Maine 04843

Dates: Wednesdays - June 4, 11, 18, & 25

Time: 5:00-6:30pm

Facilitators: Emma Schurink, SEP, CLC & Alexandra Whitney, PhD, SEP

Cost: $125 (payments can be made via cash, check or venmo - @Emma-Schurink)


Welcome to Making our Way Home. Thank you for your interest in our Somatic Experiencing® (SE™) trauma healing program. We look forward to supporting you on this leg of your healing journey. Please set aside 20 minutes to answer the following confidential questionnaire as openly as possible. This will provide us with helpful information so that we can fully support you during the program.


Trauma isn’t just an event that happened in the past—it lives on in our bodies. When overwhelming experiences exceed our capacity to cope, the nervous system stores fragments of that experience as tension, numbness, anxiety, depression, fatigue, hyper-vigilance, or unexplained pain. This is the body’s survival wisdom: trauma gets "stuck" not in our minds alone, but in our muscles, breath patterns, and even our heartbeat. Healing, then, is not about revisiting the story—it’s about rewiring the nervous system’s response to life so that we can return home to ourselves.


Somatic Experiencing offers a frame work for helping our nervous system to get unstuck and to release the holding patterns of traumatic stress and tension. During our time together we will introduce you to some of the key concepts and tools of SE that will help us to explore new rhythms and patterns that over time can support the release of stored trauma and chronic stress. This program is an initiation into understanding the connection between the mind, body, and nervous system; opening the doorway to more ease, safety and resilience. Through our Somatic Experiencing tools, you’ll have the opportunity to:



  • Explore nervous system regulation and resilience 


  • Work with body awareness to gently unwind tension and unresolved stress


  • Cultivate grounding and resourcing practices 


  • Develop tools to feel more anchored and present in daily life


Please note: This application is confidential. Its purpose is to help us understand potential needs that might arise as a result of our program material. It will also help us to maintain a safe environment for all and to offer you our best care. We hold your history with utmost respect and we honor your privacy. Upon completion of your application Emma or I will contact you to set up a time to meet via phone or zoom prior to the start of the program.


Contact us if you have any questions or concerns while filling out this application. You can email us at eightfoldpath501c3@gmail.com or call Alexandra at (303) 588-4939.


With care,

Alexandra & Emma

PERSONAL INFORMATION
* Full Name
0/50
* Preferred Name/nickname
0/50
* Phone Number
0/50
* Email
0/50
* Birthdate
0/50
* Pronouns
0/250
* What is your level of professional satisfaction?
least satisfied
most satisfied
* What is your level of life satisfaction
least satisfied
most satisfied

OVERVIEW
* Please explain your reason for attending this workshop. What are your therapeutic goals?
0/250
* Describe your social or family support system and other supports you have in life
.
0/250


* Do you have any current medical concerns?
0/250

TRAUMA HISTORY
* Have you been diagnosed (or self diagnosed) with PTSD or C-PTSD? If yes, please explain.
0/250
Have you experienced any of the following potential traumas? Please check all that apply.
* Have you are do you currently experience any of the following symptoms?

SUBSTANCE USE HISTORY
* Do you have a current or past history of substance use or abuse? If, yes, what is your substance of choice, amount, frequency, route? Age of first use? Date of last use?
0/500
* Do you use Marijuana medicinally or recreationally? If yes, please explain and include for how long, reason, amount, frequency and type.
0/250
* Are you currently in recovery? If, yes, what does recovery mean to you? What is your program?
0/250

THERAPEUTIC 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 worked with a Somatic Experiencing Practitioner? If yes, please describe your experience and include the name of your practitioner.
0/250

SOCIAL HISTORY
* What is your relationship status?
* Who is living in your home? (spouse, partner, children, parents, friends, pets etc.)
0/250
* Please indicate important relationships with persons not in your home (family, friends, etc.)
0/250

ADDITIONAL INFORMATION
Is there anything else that you would like for us to know about yourself?
0/250
* Please list 3-5 ways that you practice self-care.
0/250
Submit Application
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