Name:___________________________________ Date:_______________________
How much emotional distance did you experience in the imagery session today between your current self and your traumatized self?
0 not at all	1	2	3	4	5 very distant
How difficult was it for you to be supportive of your past self in this imagery session?
0 not at all	1	2	3	4	5 very difficult
What were your feelings about your past self on deployment in this imagery session?
Anger/Rage
0 not at all	1	2	3	4	5 very strong
Helplessness
0 not at all	1	2	3	4	5 very strong
Care
0 not at all	1	2	3	4	5 very strong
Sadness
0not at all	1	2	3	4	5very strong
Love/ Affection
0 not at all	1	2	3	4	5 very strong
Rejection/ Aversion
0 not at all	1	2	3	4	5 very strong
Guilt
0 not at all	1	2	3	4	5 very strong
Shame
0 not at all	1	2	3	4	5 very strong