Healing Developmental Trauma

Your Application Data

We understand the potential sensitivity facing some of the questions below. This can be a very vulnerable area in your life. This information is valuable to us for knowing and understanding you better which enables us to make an educated determination about your attendance in the program. We strive to offer the most appropriate and best possible care & support for you. Please answer honestly. These questions and answers are strictly confidential and will be reviewed only by the Training facilitation & coordination team.

Please confirm that your information is accurate at the end of the form before you submit your application. Thank you so much!

Personal Information

Full Name *

Phone *

Email *

Date of birth

Country of Residence *

Gender

Medical Questions

Are you currently seeing a counselor, psychiatrist, or psychologist? *

Yes

When did you start going, and how often do you have sessions? *

Are you now being treated or have you ever been treated for any mental health conditions, including, for example (but not limited to) PTSD, psychosis (including drug-induced psychosis), chronic anxiety, bi-polar disorder, and sleeping disorders that required taking any form of medication and/or hospitalization? *

Yes

Please tell us more about your treatment in regards to the mental health conditions. *

Have you ever been a patient in a mental health care facility? *

Yes

Please give as precise details, and reason as possible. *

Are you currently taking or have been prescribed psychiatric medications? If yes, please share which prescriptions, for what diagnosis, for how long and the results? *

Yes

Please share which prescriptions, for what diagnosis, for how long and the results? *

Have you ever been diagnosed with any type of personality disorder?* *

Yes

Please give precise details of what personality disorder and when when you were diagnosed *

Are you currently under the care of a medical doctor? *

Yes

Please provide the details of the nature for this care. *

Final Questions and Comment

Experience *

Why BBTRS®? *

What do you hope to take away from attending this event? *

How did you find us? *

Add a message if you wish.

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