Safe and Sound Intake Form – Adult

To ensure we provide you with the most effective and tailored experience, we kindly request that you complete this intake form. Your input will help us better understand your unique needs and goals, enabling us to craft a personalized program that best suits you.

Thank you for taking this crucial first step towards transformative change.

Safe and Sound Intake Form – Adult Form
An Invitation for an Autonomic Conversation:

As we start to consider the delivery of SSP for you, it will be helpful if you could please answer the following questions as honestly as you can. Please be assured that the information you share with me is confidential.

As you will see, this is different from more traditional assessments or intake forms you may have experienced in the past. There are no rights or wrongs here. Instead, it is designed to give me more information about your current circumstances. You will see that there are two sections to this form for you to complete: one for you to share details about your experiences, and the other about resources available to you.

The details you share with me will help us work together to explore what will be the best way to move forward in your SSP journey. It is usually better if you don’t spend too much time considering how to answer each question, as your initial response is often the most helpful to share. There are spaces for you to write more information that you think may be relevant or helpful for me to know.


Questions and Conversation Topics

1. Sound sensitivity
Check all that apply and provide details:
2. General sensory sensitivity
Check all that apply and provide details:
3. Prior listening experience:
a. Prior completion of the SSP or other listening therapies?
b. How does music affect you generally?
4. Nervous system tendency

When reacting to distressing events, it is normal to quickly move out of a restful (ventral vagal) state of social engagement and connection, and into a survival state.

There are two general types of survival responses or defensive states and we usually tend to move towards one more than the other. These two types are:

  • Activation/mobilization (sympathetic hyper-arousal)
  • Shutdown/immobilization (dorsal vagal hypo-arousal)

Please use the lists of descriptors below to help you consider which you tend more toward.

Please note that while these words may have a negative tone, both states are important and valuable supports of the body. You may find it helpful to circle the words and behaviors that apply to you.

a. In sympathetic hyper-arousal you might feel:
b. In sympathetic hyper-arousal you might display the following behaviors:
c. In dorsal vagal hypo-arousal you might feel:
d. In dorsal vagal hypo-arousal you might exhibit the following behaviors:
e. After comparing the feelings and behaviors of sympathetic activation and parasympathetic dorsal vagal shutdown, when reacting to distressing events I tend more toward:

In contrast to the two defensive states above, when you are at rest and cues of safety outweigh any cues of danger in your environment, you may be in a ventral vagal state where you can be socially engaged, calm, have impulse control, and generally experience feelings of wellbeing.

Please use the lists of descriptors below to help you consider which you tend more forward.

f. In a ventral vagal calm state , you might feel:
g. In a ventral vagal calm state , you might exhibit the following behaviors:
h. I have experienced feeling safe and being in a ventral vagal state and can relate to these descriptors.
5. Home environment
a. Describe your general feeling at home:
b. Describe the noise levels at home:
c. Describe the people in your home:
7. Access to support:
a. Do you have a reliable, caring person at or close to home who could support you during your SSP journey?
b. Will you have access to the same quiet space for your SSP listening sessions during remote delivery, and will your privacy in these sessions be respected?
c. Will you have access to a peaceful, supportive environment to practice self-regulation between sessions and after completing SSP?
d. Areyour relationships with the people in your life generally supportive?
e. Access to other nurturing and supportive resources (self-regulation): Check all that apply:

8. Unforseen Circumstances

Although there is always the possibility of unforeseen circumstances, it is helpful to know if there are any significant events likely to happen in your life which may have an impact on your ability to benefit from SSP. It is helpful to be aware of these in advance, if possible, so they can be factored into the timing of SSP delivery.

b. In addition to considering your current personal circumstances, it is also helpful to reflect on the larger world and how current events and the background situation (i.e. weather, politics, crime, contagious diseases...) may be affecting you. Does your life and world feel comfortable?

9. Engagement

 Before starting your SSP journey it is important you understand that this is a process you are engaging in for yourself and you will have the opportunity to learn new ways to help you stay more steady and regulated in the future.

Although the listening is passive, the work to sustain the experience is intentional, and requires active engagement from you throughout.

a. Do you have a willingness to engage and participate fully in the process with me as your SSP provider, and understand that the SSP is not a quick fix, or a stand-alone therapy?

Jennifer Muller

Tomatis® Level 4 Consultant