We ask that you fill out the attached Trauma History Screening before your appointment today. If you have difficulty answering the questions on this screening, please alert the intake clinician so that he/she may assist you with filling it out.
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Directions: Ask how many times each event happened, and how much
it affected the child when it happened and now (the worst time).
1) Has your child ever been in or seen a very bad accident?
2) Has your child ever had someone s/he knows been so badly injured or sick that s/he almost died?
3) Has your child ever known sombody who died?
4) Has your child ever been so sick or hurt that you or the doctor thought s/he might die?
5) Has your child ever been unexpectedly separated from someone who s/he depends on for love or secuirty for more than a few days?
6) Has your child ever had somebody close to him/her try to kill or hurt themself?
7) Has your child ever been physically hurt ot threatened by someone?
8) Has your child ever been robbed or seen someone get robbed?
9) Has your child ever been kidnapped by somebody?
10) Has your child ever been in or seen a hurricane, earthquake, tornado, or a bad fire?
11) Has your child ever been attacked by a dog or other animal?
12) Has your child ever seen or heard people physically fighting or threatening to hurt each other?
13) Has your child ever seen or heard somebody shooting a gun, using a knife, or using another weapon?
14) Has your child ever seen a family member arrested or in jail?
15) Has your child ever had a time in your life when s/he did not have the right care (e.g. food, clothing, a place to live)?
16) Has your child ever been forced to see or do something sexual?
17) Has your child ever seen or heard someone else be forced to do something sexual?
18) Has your child ever watched people using drugs (like smoking, sniffing, or using needles)?
19) Has your child ever seen something else that was very scary or where s/he thought somebody might get hurt or die?
Parent Version
Lang, J.M., & Franks, R. (2007). Adapted from the TESI (Ford & Rogers, 1997) and the THQ (Stover et al., 2007)