Faith Squared Dance

Name

First NameLast Name

1. Symptom Severity - Based on the past month

1a. I am concerned about the ways my symptoms have been interfering with my daily life.

1b. I am more concerned about my physical symptoms than my emotional state.

1c. Compared to a year ago, my symptoms are:

2. Emotional State - Based on the past month

2a. I am feeling overwhelmed by stress responses and emotional responses.

2b. I am more concerned about my emotional state than my physical symptoms.

2c. Compared to a year ago, my emotional state is:

3. Perceived Control - Based on the past month

3a. I have been unaware of tools I can use to meaningfully influence my health and well-being.

3b. I have been aware of tools I can use to meaningfully influence my health and well-being, but don't use them regularly.

3c. I've been aware of some of the tools, have used them, and have found them ineffective.

3d. I've been successful in regularly using tools that meaningfully influence my health and well-being.

3e. Are you currently and regularly using any specific brain-retraining tools? If so, please check below all that apply, and list frequency and how long you've been using them. Please continue with your current practices while also NOT introducing any other new practices / modality other than Faith Squared Dance, so that we may measure results with greater accuracy. (We do not want to block you from trying a new practice if you feel strongly that it may help you, but we do request that you let us know, as it will affect our data collection.)

How long / how frequently?

How long / how frequently

How long / how frequently?

Type a question

How long / how frequently?

3e. Compared to a year ago, my perception of control over my symptoms and emotional regulation is:

4. Relationship to Symptoms - Based on the past month

4a. When symptoms arise, I feel helpless and/or hopeless.

4b. When symptoms arise, I feel angry or frustrated.

4c. Compared to a year ago, my relationship with my symptoms is:

5. Expectations

5a. I am confident that brain-retraining practices have been shown to be effective in addressing neuroplastic symptoms.

5b. I am confident that my current symptoms are neuroplastic.

5c. I am confident that my current emotional regulation challenges are neuroplastic.

5d. I am confident that FAITH SQUARED DANCE has the potential to help improve my symptoms and/or emotional state.

6. Current Coping Strategies - Based on the past month

6a. When symptoms or a sense of being overwhelmed arises, I typically:

6b. My honest thoughts about the effectiveness (or lack thereof) of my current coping strategies are as follows:

7. I am participating in this program and the accompanying data collection processes for the following reasons:

IMPORTANT: As with any healing journey, understand now that you may feel worse before you feel better. The brain likes familiar territory, even if it is a place of suffering. So it often revives old symptoms (or even drums up new ones) to get your attention, hoping you will read that as a sign to stop whatever you’re doing to make changes and move toward recovery and healing. Dr. John Sarno called this the symptom imperative. It will pass, and it will pass more quickly if you respond calmly and without fear. Recognize it for what it is – a diversionary tactic by the brain – and refuse to give it power by focusing on it. Observe it with curiosity, and get on with whatever you were doing. Keep on the path, use your tools. Slow down and regroup if you need to, and remember – This Too Shall Pass.