Forms for The Safe and Sound Protocol

Dear Colleague, 

We have received a referral from your client for the Safe and Sound Protocol (SSP). SSP is an evidence-informed intervention based on Stephen Porges' Polyvagal theory. It is an adjunctive intervention meant to enhance rather than replace other forms of psychological therapy. It is administered over 5 to 10 days (ideally consecutive), and designed to reduce stress and auditory sensitivity while enhancing social engagement and resilience. 

To participate in SSP at our practice, we require clients to be receiving treatment from a registered mental health practitioner. Our facilitators, while they are mental health professionals, they will not be providing your client with mental health therapy.

The SSP facilitator will require some background information from you in order to create an appropriate SSP treatment plan. We greatly appreciate you filling out the following forms.

Kind regards, 

Lesley Hartman, M.A. R. Psych.

Lesley Hartman & Associates Inc.

Assessment Measures Form

ACE Score


Final Review/Assessment

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