The information you provide below will available to meditators-in-distress from Cheetah House.
Basic Information

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1. Name

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2. E-Mail Address

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3. Age

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4. Gender and preferred pronouns

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5. Location (City, State, Country)

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6. Languages (you offer sessions in)

Education & Training

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7. Field and Highest degree

  No formal training Certification Masters degree Doctoral degree (PhD, PsyD) Medical degree (MD, ND, OD)
Clinical Psychology
Counseling
Social work
Marriage and family therapy
Occupational Therapy
Nursing
Osteopathy
Naturopathy
Medicine
Psychiatry
Acupuncture
Rolfing
Massage
Life Coaching
Meditation teacher
Yoga teacher

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8. License # and state(s)/region(s)

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9. Are your services  limited  to a certain geographical area?

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10. Do you do online / video sessions?

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11. Describe your fee structure (volunteer/no fee; fee per session, sliding scale, etc.)

  No Yes Contact me
Volunteer/ no fee, or optional donation only
Offer Pro Bono sessions?
Student special rate?
Sliding scale?
Take insurance?
Specialties and approaches

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12. Specialties: Please indicate the extent that you work with the following

  not at all a little a moderate amount fairly often all the time
anxiety, panic
OCD, phobias
depression
grief
trauma /PTSD/flashbacks
childhood trauma/Complex PTSD
developmental disorders (autism spectrum)
ADHD
psychosis/schizophrenia
mania/bipolar disorder
change in sense of self
dissociation- depersonalization/derealization
emotional blunting, loss of motivation
structural dissociation (DID)
anger, irritability
borderline personality disorder
substance abuse/addiction
relationships, attachment
domestic violence
sexual assault
religious, spiritual abuse/trauma
religious/spiritual issues  (faith, worldview)
leaving a spiritual community
existential issues, meaning
involuntary movements/non-epileptic seizures
perceptual issues (visual lights, light/sound hypersensitivity)
pain syndromes
headaches
fatigue
insomnia
sexuality issues
sexual orientation issues
gender identity issues
systemic trauma (discrimination of minority groups)
social justice/activism
medication consultation (prescribers only)

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13. Approaches: Indicate the extent to which you are likely to use each approach with meditators-in-distress

  Not likely a little a moderate amount highly likely
Biomedical (Psychiatry)
Clinical Neuroscience
Evidence-based clinical psychological science
Prolonged Exposure
Cognitive Behavioral Therapy (CBT)
Somatic Experiencing
Sensory Motor Training
EMDR
Hakomi
Internal Family Systems (IFS)
Acceptance and Commitment Therapy (ACT)
Motivational Interviewing
Mindfulness
Buddhist Psychology
Spiritual Emergency
Shamanic
Touchwork/Bodywork
Reiki/Energy work
Rolfing
Acupuncture
Trauma-Specific Training

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14. Indicate degree of trauma-specific training

  No formal training Some formal training Certified
Somatic Experiencing
Sensory Motor
Prolonged Exposure
EMDR
Touch Skills for shock trauma
Somatic Resilience + Regulation for developmental trauma

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15. Other trauma-specific modality training? Specify:

Experience with Meditation-Related Difficulties

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16. Please specify the number of meditators-in-distress you have worked with as clients:

0 500
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i We adjusted the number you entered based on the slider’s scale.

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17. Meditation safety training?
Indicate below your degree of training in meditation-related difficulties.

  no yes what's that?
Attended a 3-day LIVE First Do No Harm meditation Safety Training (2018-23)
Completed the Cheetah House First Do No Harm Level 1
Completed the Cheetah House First Do No Harm Level 2 (A,B, C, D)
Completed the Cheetah House First Do No Harm Level 3 Practicum
Completed All 4 levels of Cheetah House First Do No Harm Training
Completed David Treleaven's Trauma-sensitive Mindfulness course
Have read David Treleaven's book Trauma-sensitive Mindfulness

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18. Other training in meditation-related difficulties? Describe:

Meditation Experience

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19. Choose which best describes your meditation experience

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20. How many silent retreats (greater than 1 week) have you done?

0 100
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i We adjusted the number you entered based on the slider’s scale.

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21. What is the longest retreat you have completed?

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22. Are you or have you ever been a meditation teacher?

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23. What extent do you have meditation training in the following traditions?

  None  A little  a moderate amount a great deal I'm a teacher in this tradition
Theravada
Vipassana (S.N. Goenka)
Western Insight
Zen
Tibetan
Vajrayana
MBSR/MBCT
TM
Siddha Yoga

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24. What is your personal experience with meditation-related difficulties?

  No Yes We can discuss in person
I've had meditation-related difficulties myself
I've had meditation-relate difficulties that impaired my ability to function
My own meditation-related difficulties are why I want to be a helper on the Cheetah House website
Someone close to me had meditation-related difficulties

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25. Other experience relevant for working with meditation-related problems?

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26. Anything else you want people to know about you?

Your Profile

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27. Your Profile: Use this space to describe your services include your training, approach, and specialities etc. This description will appear next to your photo on the website, with a link to a downloadable PDF of the rest of this survey.

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28. Profile photo

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29. How would you like meditators-in-distress to contact you for services? Trauma.org website? personal website? email? phone?

Agreements

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30. Cheetah House services are based on client feedback. Do you agree to have your name or company listed for periodic ratings of resources (books, videos, providers etc)?

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31. By submitting this survey, I agree to have all of the information that I provided in this survey to Cheetah House clients

T