Childhood Trauma Survey
Can you describe your childhood experience?
Did you experience any form of abuse during your childhood?
Yes
No
If yes, please specify the type of abuse (physical, emotional, sexual, neglect)
Have you sought professional help to address your childhood trauma?
Yes
No
If yes, what type of therapy or treatment did you receive?
Do you feel that your childhood trauma has impacted your adult life?
Yes
No
If yes, please describe how it has impacted your life
What coping mechanisms have you developed to deal with the effects of childhood trauma?
Have you disclosed your childhood trauma to anyone?
Yes
No
If yes, who have you disclosed it to and what was their response?
On a scale of 1 to 10, how would you rate your current mental well-being?
1 (Poor)
1
2
3
4
5
6
7
8
9
10 (Excellent)
10
1 is 1 (Poor), 10 is 10 (Excellent)
How has your childhood trauma affected your relationships with others?
Please rate the impact of childhood trauma on the following aspects of your life:
Rows
Work
Education
Health
Social Life
Hobbies
Very Negative
1
2
3
4
5
Negative
6
7
8
9
10
Neutral
11
12
13
14
15
Positive
16
17
18
19
20
Very Positive
21
22
23
24
25
Submit
Should be Empty: