Child Trauma Screening Questionnaire
Parent or Guardian Name
Please enter a valid phone number.
Age of Child
Are you a first responder or family of first responder?
Referring clinician (if applicable):
Would you like us to submit these results to the above clinician?
Please indicate if any of these things have happened to you since the incident:
Do you have lots of thoughts or memories about the incident that you do not want to have?
Do you have bad dream about the incident?
Do you feel or act as if the incident is about to happen again?
Do you have bodily reactions(such as a fast-beating heart, stomach churning, sweating and feeling dizzy) when reminded of the incident?
Do you have trouble falling or staying asleep?
Do you feel grumpy or lose your temper?
Do you feel upset by reminders of the incident?
Do you have a hard time paying attention?
Are you on the "look-out" for possible dangerous things that might happen to yourself or others?
When things happen by surprise or all of a sudden, does it make you "jump"?
Should be Empty: