What is your full name? ^*

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What is your age? ^*

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What is your email? ^*

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What timezone are you in? ^*

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How has DPDR affected your emotions? ^*

For example:
- How often do you feel emotions?
- Do you feel no emotions? Intense emotions?
- Only sadness? Only happiness?
- Can you read other people's emotions?
- What can you feel emotions toward? What can't you feel emotions toward?

Please provide as much information as possible, this helps us match you with the best group. If this question if not relevant to your experience, write N/A.

/

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How has DPDR affected your executive functioning? ^*

For example:
- Do you struggle with your memory? Are there particular memories that are hard to retrieve?
- Is your mind active or does it feel blank?
- Do you have an internal monologue or do you no longer recognize thoughts?
- Do you struggle to frame and solve problems?

Please provide as much information as possible, this helps us match you with the best group. If this question if not relevant to your experience, write N/A.

/

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How has DPDR affected your thoughts? ^*

For example:
- Do you have an internal monologue or do you no longer recognize thoughts?
- Are your thoughts positive or negative? What are they about?
- Do you have existential or instrusive thoughts?

Please provide as much information as possible, this helps us match you with the best group. If this question if not relevant to your experience, write N/A.

/

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How has DPDR affected your internal sensations? ^*

For example:
- Do you feel intense anxiety? No anxiety?
- Do you feel pressure anywhere in your body (e.g., head, chest)?
- Are you able to laugh and cry?
- Do you feel connected or disconnected from your five senses (e.g., taste)?

Please provide as much information as possible, this helps us match you with the best group. If this question if not relevant to your experience, write N/A.

/

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How has DPDR affected your perception of the world? ^*

For example:
- Does time feel like it's moving faster? Slower?
- Do you feel like the world is not real? Like you're living in a simulation?

Please provide as much information as possible, this helps us match you with the best group. If this question if not relevant to your experience, write N/A.

/

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How has DPDR affected your perception of yourself? ^*

For example:
- Do you identify with your name? Face? Body? Character traits?
- Do you feel like you are disconnected from your body?

Please provide as much information as possible, this helps us match you with the best group. If this question if not relevant to your experience, write N/A.

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How has DPDR affected your field of vision? ^*

For example:
- Do objects appear larger than they actually are? Smaller?
- Do you have floaters or visual snow in your field of vision?
- Do you have tunnel vision?

Please provide as much information as possible, this helps us match you with the best group. If this question if not relevant to your experience, write N/A.

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Whew, that was a lot

Take a deep breath, we're almost at the end.

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How long have you been experiencing DPDR? ^*

Less than 1 year

1 - 5 years

More than 5 years

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Which of the following do you think caused you to start dissociating?

You can select more than one.

Anxiety (e.g., general, social, panic attacks)

Drug experience (e.g., marijuana, psilocybin, LSD, ketamine)

Trauma (e.g., physical, sexual, emotional, medical)

Neurologic condition (e.g., seizures, migraines, traumatic brain injury)

Substance use over time (e.g., alcohol, opioids, nicotine, simulants)

Medication (e.g., antidepressants, benzodiazepines, antipsychotics, ADHD medications)

Other

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What stressors / anxieties led your brain and body to cope by dissociating?

For example: career, finances, physical safety, perfectionism, health anxiety, relationship, phobia, existential, panic disorder, social anxiety

Please provide as much information as possible, this helps us match you with the best group. If this question if not relevant to your experience, write N/A.

/

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What substance led your brain and body to cope by dissociating? How frequently did you consume it?

For example: marijuana, psilocybin, LSD, DMT, MDMA, ketamine

Please provide as much information as possible, this helps us match you with the best group. If this question if not relevant to your experience, write N/A.

/

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What type of trauma led your brain and body to cope by dissociating?

For example:
- Physical (e.g., violence, accidents, childhood abuse, physical abuse)
- Sexual (e.g., sexual assault / rape, childhood sexual assault, human trafficking)
- Emotional (e.g., emotional abuse, bullying and harassment)
- Medical (e.g, chronic condition, surgery, birth, disability)
- Relationship (e.g., neglect, abandonment, divorce, breakup, codependency)
- Loss / Grief (e.g., death, suicide, natural disaster, ambiguous loss)

Please provide as much information as possible, this helps us match you with the best group. If this question if not relevant to your experience, write N/A.

/

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What neurologic condition led your brain and body to cope by dissociating?

For example: seizure disorder, migraines, traumatic brain injury, fibromyalgia, psoriasis, multiple sclerosis, stroke

Please provide as much information as possible; this helps us match you with the best group. If this question if not relevant to your experience, write N/A.

/

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Misuse of which of the following substances led your brain and body to cope by dissociating?

For example: alcohol, opioids (e.g., heroin, morphine), nicotine, stimulants (e.g., adderall, cocaine), benzodiazepines (e.g., xanax)

Please provide as much information as possible; this helps us match you with the best group. If this question if not relevant to your experience, write N/A.

/

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Which of the following medications led your brain and body to cope by dissociating?

For example: antidepressant (e.g., zoloft), benzodiazepines (e.g., xanax), stimulants (e.g., adderall), antipsychotics (e.g., abilify)

Please provide as much information as possible; this helps us match you with the best group. If this question if not relevant to your experience, write N/A.

/

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Is there anything else that may have contributed to your brain and body feeling the need to cope by dissociating?

Feel free to add anything that comes to mind.

/

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What other group characteristics are important to you?

For example:
- Mental health conditions (e.g., OCD)
- Occupation (e.g., student, mom, professional)
- Gender
- Religion
- Sexual Orientation

For example: I would like to be with other students experiencing depression.

We will do our best to honor these preferences, but we cannot guarantee that your group will be fully comprised of these characteristics.

/

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Congratulations!

You made it to the end of the intake form.

More importantly, you just took a big step forward in your recovery. We will reach out once we find a group that matches your preferences!

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Embodi Interest Form

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