Safe and Sound Intake Form – Child

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 – Child Form
Note to Parent:

As we start to consider the delivery of SSP for your child, 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 questionnaires you may have completed in the past. There are no rights or wrongs here. Instead, it is designed to give me more information about your child’s 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 child’s experiences, and the other about resources available to them.

The details you share with me will help us work together to explore what will  be the best way to move forward in your child’s SSP journey. 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 your child 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 below to help you consider which state your child tends toward more. It is helpful to circle the descriptors that apply.

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

a. In sympathetic hyper-arousal they might feel:
b. In sympathetic hyper-arousal they might display the following behaviors:
c. In dorsal vagal hypo-arousal your child might feel:
d. In dorsal vagal hypo-arousal your child might exhibit the following behaviors:
e. When reacting to distressing events my child tends more towards:

In contrast to the two defensive states above, when your child is at rest and cues of safety outweigh any cues of danger in their environment, they will be in a ventral vagal state where they can be socially engaged, calm, have impulse control, and generally experience feelings of well being.

Please use the lists below to help you consider which state your child tends toward more. It is helpful to circle the descriptors that apply.

f. In a ventral vagal calm state , your child might feel:
g. In a ventral vagal calm state , your child might exhibit the following behaviors:
h. I have observed my child feeling safe and in a ventral vagal state and can relate to these descriptors.
5. For Parent: Your own nervous system tendency

Just as your child’s nervous system tendency can help to guide their SSP facilitation plan, it is also helpful to know what your tendency is as a parent since this may also be a consideration in the approach. So please respond to the following questions- this time for yourself.

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

a. In sympathetic hyper-arousal you might feel:
b. In sympathetic hyper-arousal you might exhibit the following behaviors:
c. In dorsal vagal hypo-arousal you might feel:
d. In dorsal vagal hypo-arousalyou 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:
6. Child Resources
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 (co-regulation) from others:
a. Will a reliable, caring adult be able to support this child’s experience with the SSP and to co-regulate with them?
b. Will you and your child have access to the same quiet space without interruptions for the SSP listening sessions during remote delivery?
c. Will your child be supported to practice self-regulation between sessions and after completing SSP? Will they have access to healthy coregulation?
d. Are the relationships your child has with the people in their 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 child’s life or those close to them which may have an impact on their 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 general, how would you assess your child’s and your family’s current situation and experience? Does their life and world feel comfortable?

9. Engagement
Before starting your child’s SSP journey, it is important you understand that this is a process you are engaging in together. It may require extra support of your child as their nervous system shifts and repatterns. 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 with your child 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