Version 1.2 — Confidential · Protected under HIPAA
Before we begin — there are no right or wrong answers. This questionnaire helps your clinician understand you more deeply before your first session. A real clinician will personally review everything you share.
This uses AI-assisted pattern recognition to prepare your clinician. It does not make clinical decisions. All clinical decisions are made by your licensed therapist.
Phase 1 — Memory Gateway
Q1-A
Think back as far as you can. How accessible are your early childhood memories?
A
Clear + vivid
Detailed, specific memories going back to a very young age.
B
Scattered / hazy
A few memories, but things feel fragmented or out of reach.
C
Mostly blank
Early childhood feels largely or entirely inaccessible before a certain age.
⚑ Clinician alert
Phase 1 — Memory Gateway
Q1-A follow-up
Approximately what age do your clearest memories start?
A
Before age 4
Likely developmentally typical — very early memory before age 4 is common.
↳ Standard path
B
Age 4–9
Moderate flag — worth exploring with your clinician.
⚑ Moderate memory gap noted
C
Age 10 or older
Significant memory gap for a period where clear recall is expected.
⚑ Elevated memory gap — clinician alert
Phase 1 — Memory Gateway
That's okay — some people find that early memories aren't easily accessible. We're going to ask a few different kinds of questions that don't rely on specific memories.
Phase 1 — Memory Gateway
Q1-B
For the memories you can access, what is their primary emotional tone?
Select all that apply.
A
Mostly happy / secure
Generally positive, warm, or neutral. I felt safe.
↳ Standard Sensitivity Path
B
Painful / lonely / heavy
Feelings of being misunderstood, isolated, anxious, or heavy emotional weight.
⚑ Early emotional distress
C
Fearful / abusive / chaotic
Direct fear, unpredictability, intimidation, or physical and emotional abuse.
⚑ High Trauma / Safety Alert
D
Mixed — it depended
Some memories feel safe or warm; others feel frightening, heavy, or painful. It wasn't consistent.
⚑ Mixed attachment / mismatch path
Phase 1 — Memory Gateway
Thank you for sharing that. Your clinician will personally review your responses before your first session.
Q1-C — What primary forms did that take? Select all that apply.
A
Verbal / emotional
B
Physical
C
Neglect / abandonment
D
Combination of multiple types
How frequently did these experiences occur?
A
Once or a few isolated times
B
Occasionally
C
Regularly — a recurring part of my childhood
⚑ Chronic abuse pattern
D
Constantly — it was the environment I grew up in
⚑ Pervasive / complex trauma
Optional — anything else for your clinician?
A clinician will personally review your responses before your first session.
Phase 1 complete. Moving to Phase 2 — Sensitivity Baseline.
Phase 2 — Sensitivity Baseline
Research shows some people are born with a more reactive nervous system — they feel things more deeply. This is not a weakness.
Q2
Growing up, how would you describe your natural reaction to your environment compared to other kids?
A
Highly reactive / sensitive
Easily overwhelmed by loud noises, bright lights, criticism, strong smells, or emotional moods of adults.
B
Moderately adaptive
I noticed things, but could usually brush them off or roll with the punches.
C
Numb / detached
I felt largely disconnected from my surroundings or my own body.
⚑ Dissociative indicator
Phase 2 — The Orchid Index
Q2 follow-up — Select all that apply.
As a sensitive child, how did you most frequently cope with overwhelming stress?
A
Internalized shielding
Tried to be good, quiet, or perfect to avoid making waves.
B
Withdrawal and isolation
Retreated into my room, books, or imagination — or shut down.
C
External defense
Pushed back, argued, acted out, or used anger and defiance.
D
Early self-soothing / numbing
Sought physical comforts, food, repetitive behaviors, or early substances.
⚑ Early numbing behavior
E
External support
I was able to talk to a safe adult who helped me regulate.
✓ Protective factor
Phase 3 — Environmental Mismatch
Q3
How did the adults in your household handle the different personalities or needs of the children?
Select all that apply — your household may have had more than one dynamic.
A
The uniform rulebook
Strict, one-size-fits-all standard. Individual differences not accommodated.
⚑ Environmental mismatch risk
B
Individualized attunement
Adults tried to adapt parenting to fit each child's temperament.
✓ Protective factor
C
Unpredictable / chaotic
Rules changed constantly based on the adults' stress levels or moods.
⚑ Chaotic home environment
D
Absent or non-traditional household
Raised by single parent, grandparents, extended family, foster carers, or non-traditional setting.
Phase 3 — Environmental Mismatch
Q4
From the outside — what would a parent, teacher, or caregiver have seen when you were overwhelmed as a child or teenager?
Think about what your behavior looked like to others, not what was happening inside you. Select all that apply.
A
Acted out
Yelled, misbehaved, or pushed back against adults.
B
Shut down
Withdrew, hid, went quiet, or disappeared into yourself.
C
Expressed it
Shared feelings verbally or through creative outlets like art, music, or writing.
✓ Healthy expressive coping
D
Sought comfort
Looked for physical soothing, food, screens, or anything that made the feeling quieter.
E
Tried to fix it
Became the peacemaker, caretaker, or the good one to reduce tension around you.
⚑ Fawn response pattern
Phase 3 — Environmental Mismatch
Q5
When you behaved in that way, how did the adults — parents, teachers, or caregivers — typically respond?
A
Ignored or overlooked
My withdrawal or behavior went completely unnoticed or unaddressed.
⚑ Invisible distress
B
Punished or scolded
Criticized, shamed, or met with strict anger for showing big emotions.
⚑ Shame response conditioned
C
Minimally accommodated
They let me be, but did not check in or help me process why I was overwhelmed.
⚑ Partial attunement
D
Attuned and supportive
They noticed, offered a safe space, validated, and helped me through the emotional state.
✓ Secure attachment
Phase 4 — Compensatory Trajectory
By adulthood, our nervous systems have developed strategies — often unconscious — to manage the stress load we carry. These patterns are not character flaws. They are adaptations.
Q6 — Select all that apply.
What primary tools did your nervous system use to cope with overwhelming stress or chronic internal pressure?
A
Internalizing
Chronic anxiety, perfectionism, overworking, relentless self-criticism, or silently shutting down.
B
Substance use / numbing
Turning regularly to alcohol, drugs, excessive gaming, social media, or other numbing behaviors.
⚑ Substance use flag
C
Externalizing
Outbursts of frustration, defensive pushing away of others, impulsive decisions, or rebellious risk-taking.
D
Body-based symptoms
Chronic pain, headaches, GI issues, fatigue, or physical symptoms without clear medical cause.
⚑ Somatic flag — triggers Phase 5
E
Healthy regulation
Safe outlets, trusted mentors, spiritual practices, or tools to process stress effectively.
✓ Resilience factor
Phase 5 — Somatic Pain Assessment
People who have experienced what you have described often find that emotional pain shows up in the body — chronic aches, tension, or unexplained physical symptoms that doctors have not been able to fully explain. This is not imagined. It is a real and well-documented response of the nervous system to unresolved stress and trauma.
Q7
Do you experience body aches, tension, or physical pain that others around you don't seem to share or fully understand?
A
Yes — this resonates with me
↳ Triggers location and intensity questions
B
Somewhat — occasionally or mildly
↳ Triggers location and intensity questions
C
No — I don't notice this for myself
↳ Skips to Phase 6
Phase 5 — Somatic Pain Assessment
Q7-B — Select all that apply.
Where in your body do you feel it most?
A
Head / jaw / neck
Tension headaches, jaw clenching, throat tightness, or neck pain.
B
Chest
Tightness, heaviness, constriction, or chest pain.
C
Stomach / gut
Anxiety in the gut, nausea, digestive issues, or chronic stomach pain.
D
Shoulders / upper back
Carrying weight, chronic soreness, tightness between shoulder blades.
E
Lower back / hips / pelvis
Chronic lower back pain or pelvic tension.
⚑ Often connected to more complex trauma
F
Arms / hands
Numbness, tingling, bracing patterns, or tension.
G
Legs / feet
Heaviness, numbness, disconnection from the ground, or restless legs.
H
It moves around
Multiple shifting locations — hard to pin down.
I
Whole body / hard to pinpoint
A general heaviness, fatigue, or full-body tension.
Phase 5 — Somatic Pain Assessment
Q7-C
How much does this physical pain or tension affect your daily life?
3
Moderately disruptive — affects mood, energy, or activities regularly.
1 — Barely noticeable5 — Severely disruptive
Phase 5 — Somatic Pain Assessment
Q7-D
When did you first notice these physical symptoms?