Name * First Name Last Name Email * Phone (###) ### #### 1. Trauma Symptoms: With reference to your current situation for which you are seeking legal advice, have you experienced or are you experiencing any of the trauma symptoms listed below? Feeling isolated from others/disconnected ‘Spacing out’ (going away in your mind)/Absent-mindedness Memory problems Relative absence of physical sensation/not ‘in your body’ Reduced physical movement /immobility Scrolling down social media or equivalent endlessly Can’t defend oneself Numbing of emotions / feeling flat Finding it hard to say no to others People-pleasing/prioritising others Lethargy/low energy Lack of motivation Procrastination/Indecisiveness Sadness/uncontrollable crying Feelings of guilt Feelings of loneliness Feelings of inferiority Difficulty getting on with others Feeling things are ‘unreal’ Difficulty controlling your temper Constant tension/stress/nervousness Anxiety attacks Defensiveness Obsessive/racing thoughts Easily irritable Racing heart Dizziness Hypervigilance (feeling constantly alert to potential threat) Impulsivity Finding it hard/unable to relax Low sex drive/lack of sexual enjoyment/dissatisfaction Bad thoughts/feelings during sex Sexual overactivity/feelings when you shouldn’t have them/ Insomnia/difficulty sleeping/staying asleep/restless sleep Headaches Stomach problems/weight loss (without dieting) Fear of others Nightmares Flashbacks (sudden, vivid, distracting memories) Desire to physically hurt yourself or others Unnecessary or over frequent behaviour e.g washing Yes No If yes, on a scale of 0-5, how impactful are these symptoms on your functioning and well-being on a daily basis? 0 = never impacted 1 = rarely impacted 2 = occasionally impacted 3 = frequently impacted 4 = very frequently impacted 5 = always impacted 0 1 2 3 4 5 2. Concerns About the Legal Process: This process involves telling us your story, receiving correspondence from the other party which may be difficult in nature, or encountering them in person during mediation or in court. Are any of these a significant concern for you? Please tick as appropriate: Telling your story Receiving correspondence from the other party which is difficult in nature Encountering the other party in person at mediation/in court Encountering the other party on videolink at mediation/in court 3. Current Support System: What support do you currently have in place? Does your current support feel sufficient? Yes No 4. Additional Support Options: Would you be interested in any of the following? Information or referral to Rosefield Divorce Consultancy Information or referral to a support group Information or referral to a psychotherapist 5. Communication Preferences: Do you have any communication preferences that would be more helpful for you? (Select all that apply) Email Face-to-face meetings Phone calls 6. Consent for Use of Information: Do you consent to us reviewing your responses to help determine the best approach to support you during the legal process? Yes No Following review of your responses, do you consent to us making contact with you via your preferred method to discuss any recommendations? Yes No Thank you for completing this questionnaire. Your responses will be received by a team member at Burgess Mee and the information held confidentially. It will be used only for the purposes of ensuring that we provide the best possible support for your needs.
