Trauma Response Network

Supporting mass trauma recovery in Great Britain

Manchester Arena

Adult Request for Support Form

Please complete the form below if you wish to request EMDR therapy from one of the therapists in the TRN network. Up to 8 sessions may be offered. Times/dates will be arranged with the therapist allocated to you. Please be aware that we only offer therapy in English. If you are already seeing a therapist, please ask them for support first. We only offer support for all those who have suffered a mass trauma or are indirectly affected by such events. By mass trauma we mean wars, acts of terrorism and natural disasters. We offer therapy for this type of trauma only, even when you may have experienced other traumas.

We aim to respond to you within 6 weeks of completing the form.

Adult Request for Support Form
Which category of mass trauma have you been affected by? We only offer support for all those who have suffered a mass trauma or are indirectly affected by such events. By mass trauma we mean a traumatic event that happened to a group of people within the same timeframe such as the Grenfell disaster

Examples

Mass Trauma: where something has occurred to multiple people during a single incident - such as the Black Lives Matters riots or Grenfell or Liverpool Champions League Final Paris

Act of Terrorism: eg London Bridge Terrorist Attacks or the Manchester Arena Terrorist Attack

COVID-19: eg having experienced trauma because of the measures implemented during the pandemic

War: such as the war in Ukraine (including family members being in the war zone)

I give consent to the therapist to contact my GP about my condition and treatment if my therapist thinks it would be of benefit to me. By agreeing to have therapy with one of our therapists we will need to have consent to contact your GP if we have serious concerns about your mental health.

ASDS Tool

ASDS is the tool TRN uses to initially screen for whether it is appropriate to refer an adult to a therapist and what level of support may be required. It is a quick and simple tool to complete © Richard Bryant (1999).

Please answer each of these questions on how you have felt since the event. Select an option to rate your answer from 'not at all' (1) to 'very much' (5)
1. During or after the trauma, did you feel distant from your emotions?
2. During or after the trauma, did you ever feel in a daze?
3. During or after the trauma, did things around you ever feel unreal or dreamlike?
4. During or after the trauma, did you ever feel distanced from your normal self or like you were watching it happen from the outside?
5. Have you been unable to recall important aspects of the trauma?
6. Have memories of the trauma kept entering your mind?
7. Have you had nightmares or bad dreams about the trauma?
8. Have you felt as if the trauma was going to happen again?
9. Do you feel very upset when you are reminded about the trauma?
10. Have you tried not to think about the trauma?
11. Have you tried not to talk about the trauma?
12. Have you tried to avoid situations or people who remind you of the trauma?
13. Have you tried not to feel upset or distressed by the trauma?
14. Have you had trouble sleeping since the trauma?
15. Have you felt more irritable since the trauma?
16. Have you had difficulty concentrating since the trauma?
17. Have you become more alert to danger since the trauma?
18. Have you become more jumpy since the trauma?
19. When you are reminded of the trauma, do you sweat or tremble or does your heart beat fast?
I understand that EMDR is provided in English only and that i understand and speak proficient enough English to participate in the therapy. I confirm that I have completed this referral myself/played an active part in completing this form, and that I would like to be contacted by TRN. We aim to respond to you within 6 weeks whether you fulfil the criteria to be offered therapy by one of the EMDR therapists in our network.
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