Getting to Know Your Nervous System

The way that our nervous system responds throughout life is informed by our health, our life experiences, and how we take in information from inside and outside our bodies (sensations). Please complete this form to help your provider better understand your nervous system patterns, and where to start with listening therapies.

First name

Last name

Email

Phone

Address

Health History:

Briefly describe your mental and physical health history, including your current status, conditions, symptoms, recent procedures, or other challenges.

Do you experience any of the following related to your health?

Difficulting falling or staying asleep

Constipation or loose stool

Difficulty with swallowing, indigestion, or chest pain associated with eating

Frequent headaches or migraines

Chronic pain, chronic fatigue

Low energy, difficulty taking care of yourself or others

Muscle tension, shoulder/neck/back pain, body aches

Frequent sweating or feeling hot in the face and palms

Engaging in problematic substance use or related habits/behaviors

Personal History

Describe your relevant personal history, including difficult childhood experiences, and current or expected stressors

Sensations

Please describe how you respond to sensations in your environment (hearing, seeing, taste, smell, movement, etc.) and from within your body. Consider sensations that are pleasant or unpleasant, and how you respond to those sensations (avoidance of sound)

Do you experience any of the following related to sounds?

Certain sounds are strongly disliked

Specific sounds have to be avoided or feel unbearable

Hearing is typical, but processing and understanding what is heard is compromised

Difficulty hearing speech when there is background noise

Feeling drawn to or enjoying loud or noisy environments

Nervous System Regulation

When reacting to distressing events in our lives, it is normal for us to quickly move out of a restful, connected state and into a defensive state (e.g. fight, flight or shutdown response). Please describe how you typically respond to stress or challenges

Support

Who do you consider to be a part of your support network and how often are you in contact with them? Consider your household, family, friends and community.

What is the strength and stability of your support system?

Resources

Describe your access to resources, including basic needs like shelter, nutrition, and physical safety, in addition to access to medical care, financial security, work and education.

Preparing for Listening

Will you have access to a quiet space for listening, and will your privacy in these spaces be respected?

Will you have access to a supportive environment to practice regulation between and after listening?

Do you have access to any of the following?

Nature, open spaces, plants you care for in your home or garden, even a nice view from your window

Pets, birds in your outdoor area, relationship with other animals

Movement practice (e.g. sports, exercise routine, dance, or walking)

Yoga, meditation or spiritual practice

Breathing exercises, singing in a choir, playing a wind instrument

Other creative activities such as art, drama, or music

Other

Prior Listening Experience

Consider the role of music in your life and how music or other listening therapies have been more or less supportive of your well-being. Have you listened to the Unyte programs in the past?

Have you experienced other listening therapies?

How often do you listen to music?

What type of music do you like?

How do the above vary depending on how you feel?

Unforeseen Circumstances

Provide details of any events happening or expected in the next few weeks or months so these can be considered. (e.g. job stress, exams, medical procedures or operations, house move, recent bereavement, or life change).

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 (e.g. weather, politics, crime) may be affecting you. How does your life and world feel?

How would you like to change as a result of participating in the Unyte program? Name 2-3 goals.

Is there anything more you'd like your provider to know?

Thank you

for taking the time to thoughtfully reflect on and respond to these questions. Your provider may also request you complete one or more assessments to better prepare for your listening journey.

WILL THE SAFE & SOUND PROTOCOL HELP ME?

Getting to Know Your Nervous System

Thank you