PTSD Screening Form

This is a screening tool to help you determine whether you might Post Traumatic Disorder that needs professional attention. This screening tool is not designed to make a diagnosis but to be shared with Summit Behavioral Health mental health professional to inform further conversations about diagnosis and treatment. One of our providers will perform a free review of your form and contact you to discuss potential care options.

INSTRUCTIONS

1) Fill and submit shown form

2) Choose if you want to be contacted by Summit BHP staff

3) Select date/time for brief virtual meeting

Date *

Date

You have experienced or witnessed a life-threatening event.

Do you have intrusions about the eventin at least one of the following ways?

	Response
Repeated, distressing memories, or dreams
Acting or feeling as if the event were happening again (flashbacks or a sense of reliving it)
Intense physical and/or emotional distress when you are exposed to things that remind you of the event

Do you avoid things that remind you of the event in at least one of the following ways?

	Response
Avoiding thoughts, feelings, or conversations about it
Avoiding activities and places or people who remind you of it

Since the event, do you have negative thoughts and mood associated with the event in at least 2 of the following ways?

	Response
Blanking on important parts of it
Negative beliefs about oneself, others and the world and about the cause or consequences of the event
Feeling detached from other people
Inability to feel positive emotions
Persistent negative emotional state

Are you troubled by at least two of thefollowing?

	Response
Problems sleeping
Irritability or outbursts of anger
Reckless or self-destructive behavior
Problems concentrating
Feeling "on guard"
An exaggerated startle response

Do you consent to Summit BHP contacting you to discuss your results and care options? *

Appointment

If you answered Yes to the question above, please fill following section. We offer new patient appointments onsite and online within 1-3 days of submitting a request.

Name

First Name Last Name

Age

Gender

Phone Number

Area Code Phone Number

Summit Behavioral Health

2115 County Road D East, Suite C-100, Maplewood, MN 55109

Ph: 651-358-7020 www.SummitBHP.com

Post Traumatic Stress Disorder (PTSD) Screening Form