Getting Started with
Listening Therapy

This form helps us understand whether the Safe and Sound Protocol (SSP) is right for you at this time. Please answer honestly. Your responses will be reviewed confidentially by your provider.
You’ll hear back with next steps soon!

Contact Information

Full Name *

Date of birth

Phone *

Email *

Who will be listening ("The Listener") *

I represent someone who will be listening

Please provide their full name, date of birth and relationship to you.

Quick Questions

Hearing & Ear Health

Does the listener currently have any ear pain, infection, or recent ear surgery? *

Yes

Please provide details (e.g., type of issue, when it occurred).

Does the listener currently have ear tubes (grommets) *

Yes

Please provide details (e.g., date inserted, any issues).

Does the listener use hearing aids or a cochlear implant? *

Yes

Please provide details.

Does the listener experience tinnitus (ringing or buzzing in the ears)? *

Yes

Sometimes

Please describe (e.g., mild/occasional, severe, impacts daily life).

Sound Sensitivity

Does the listener experience strong sound sensitivity (e.g. hyperacusis or misophonia)? *

Yes

Sometimes

Please tell us more (e.g., situations, severity).

Mental Health & Neurological

Has the listener been hospitalised for mental health reasons in the past 6 months? *

Yes

Please provide us with details.

Is the listener currently experiencing thoughts of self-harm or feeling unsafe? *

Yes

Sometimes

Please share what you’d like us to know.

Does the listener have a history of psychosis, or are you currently experiencing psychotic symptoms? *

Yes

Please share relevant details.

Has the listener ever experienced seizures? *

Yes

Are your seizures currently,

Please provide relevant information

Medical & Medications

Does the listener have any significant medical conditions (e.g. neurological, autoimmune, chronic illnesses) we should be aware of? *

Yes

Please provide an overview of medical conditions and history.

Has the listener recently started, stopped, or changed any medications (especially for mood, sleep, or attention)? *

Yes

Please share a brief overview.

Developmental or Sensory Differences

Does the listener have any developmental, learning, or sensory differences (e.g. autism, ADHD, sensory processing challenges)? *

Yes

Please tell us more.

Current Context

Has the listener currently experiencing any major life stressors (e.g. grief, housing instability, crisis) that may affect your ability to participate? *

Yes

Please help us understand the circumstances.

Any Thoughts?

Please let us know if you have nay questions or comments for us?

Consent & Acknowledgement

The listener (or their representative), *

Confirms they have answered all questions sincerely and to the best of their knowledge.

Agrees to pause and contact their provider if they feel unsafe, overwhelmed, or unsure during the use of protocol.

Understands SSP must be delivered under provider guidance and should not be rushed, skipped, or repeated without direction.

Understands SSP is not a substitute for emergency care, crisis support, or medical/psychiatric treatment.

Give consent for these responses to be used by the provider to guide safe delivery of SSP.

Accepts that outcomes may vary for each person, and that SSP works best when combined with other supportive practices.

I agree to above terms provided by The Art of Wellbeing. By providing my contact details I agree to receive text messages or emails.

Date *

Signature *

Clear

THE ART OF WELLBEING
03 4722 1572

21-23 Reid Street, Wangaratta VIC 3677