3MDR Exit Form

This form should be filled out by the 3MDR clinician at the end of 3MDR therapy.

Clinician's name

Clinician's email address

3MDR patient's name

Participant ID site code (i.e. clinical location where patient received 3MDR)

Participant ID number (eg: 003)

Does the patient have a history of military-related trauma? (Select all that apply.)

Does the patient have a history of trauma related to working as a public safety personnel (PSP) - eg: police, firefighter, paramedic, correctional officer, etc.? (Select all that apply.)

Does the patient have a history of trauma related to working as a healthcare professional or service provider (Select all that apply.)

Does the patient have a history of trauma related to the workplace? (Select all that apply.)

Does the patient have a history of trauma related to any of the following? (Select all that apply.)

Does the patient have a history of childhood-related trauma? (Select all that apply.)

Does the patient have a history of trauma related to any of the following? (Select all that apply.)

Please describe any other trauma background the patient has, that is not covered by the questions above (or enter NA if not applicable):

Does the patient have any of the conditions below? (Select all that apply.)

Please summarize briefly:
How did the patient present originally (treatment history and case conceptualization)?
Specific trauma(s) worked on during 3MDR.
How did the 3MDR therapy go and how did the patient respond?
Please include any other notes or observations that would be relevant.

Please describe any themes that emerged and evolved during 3MDR therapy.

Examples of themes to consider: guilt, moral injury, shame, interpersonal trauma, not having voice, identity issues, feeling out of control, holding onto the ideal rather than embracing reality, not having a sense of belonging, disempowered, being trapped, not having choice, any other themes that were important during 3MDR therapy.

What is the plan following completion of 3MDR?