Life course/pain points/trauma questionnaire

(eg: divorce, bullying, accident, etc.)

This information is necessary to provide you with even better guidance and support during the sessions. This intake interview will remain confidential and will be kept in your personal file.

If you have any questions or comments while completing this intake form, please don't hesitate to contact us. If you can't answer certain questions, that's no problem. If we have any further questions, we will contact you.

Date of session

Name

Age

Date of birth

Month

Day

Year

Time of birth

Place of residence

GSM

E-mail

Let's start at conception... Were you a wanted child?

How did your birth go? If possible, ask about it (forceps, umbilical cord around the neck, induction, incubator, too early or too late, etc.).

What do you know about the ages between 0 and 7? (crying baby, death of a loved one, divorce, bullying at school, separation anxiety, etc.)

What do you remember about your teenage years? Did you encounter any social problems at school, for example? For example, bullying, loneliness, bad experiences with teachers, caregivers, etc.

20+ to date? Have any special (positive or negative) events occurred in your life?

Have you ever been hospitalized/had surgery?

Do you have heart problems, high or low blood pressure, or any other conditions we should know about for your safety? If so, please specify which ones.

Do you know anything about your parents' trauma?

Are any of your loved ones seriously ill or deceased?

Are you addicted or prone to addiction? Such as drugs, alcohol, food, sex, games, etc.

Are you taking or have you taken any medication? If so, which ones and for what purpose? (Including nasal sprays, painkillers, vitamins, preparations, etc.)

Do you have any physical, mental, or family history issues? Such as psychosis, borderline personality disorder, rheumatoid arthritis, etc.

Are you being treated by a therapist such as a doctor, psychologist, psychiatrist or other...?

Have you been treated for mental health issues in the past? For example, schizophrenia, psychosis, and/or epilepsy?

What is your living situation like? Do you live alone, with a partner, children, or other?

Are you experiencing certain emotions on a daily basis right now? If so, please describe them.

Describe your issue/what you are facing or physical complaints in your own words

Briefly describe the problem/issue/complaint you're facing. The cause, motivation, circumstances, and development...

What do you expect from the session?

Have you ever used drugs? Cannabis, ecstasy, or something else?

Have you ever used entheogenic substances? If so, what was your experience like? (truffles, mushrooms, etc.)

Have you ever experienced bodywork and/or breathwork? Briefly describe what that experience was like.

Are there any other physical or emotional details that are important to us?

Contra-indicaties Trauma Release Breathwork ( TRB)

Trauma Release Breathwork, ook wel DMT-ademwerk, is een methode die soms wordt gebruikt om een bewustzijnstoestand te induceren die vergelijkbaar is met de effecten van de psychedelische stof dimethyltryptamine (DMT), maar zonder daadwerkelijk DMT in te nemen.

Bij deze methode wordt diepe ademhaling gebruikt om veranderde staten van bewustzijn op te wekken.

Contra-indicaties zijn factoren of omstandigheden waarbij het sterk wordt afgeraden of gevaarlijk kan zijn om Trauma Release Breathwork te proberen.

Hierbij enkele mogelijke contra-indicaties:

-Hoge bloeddruk

-Hartproblemen

-Epilepsie

-Zwangerschap

-Ernstige psychologische klachten

-Je bent verslaafd aan psychoactieve middelen, zowel soft-als harddrugs.

-Bepaald medicijngebruik (deze heb je reeds meegedeeld in de vragenlijst)

BELANGRIJK:

-Geen drugs 2 weken voor aanvang sessie

-Geen entheogene/ psilocybine middelen 1 week voor aanvang sessie (microdosing in overleg)

-Geen alcohol 3 dagen voor aanvang sessie.

Multi choice

Ik heb kennis genomen hiervan en bevestig dat ik geen contra-indicaties heb.

Ik heb kennis genomen en bevestig dat ik wel contra-indicaties heb.

Indien contra-indicaties, welke?