Owner Trauma Assessment Survey
Please complete this survey to help us assess trauma exposure and its effects. Your responses are confidential and will assist in providing appropriate support.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
Contact Email
*
example@example.com
Have you experienced a traumatic event in the past year?
*
Yes
No
Please select the types of trauma you have experienced (select all that apply):
Accident or injury
Natural disaster
Loss of a loved one
Violence or assault
Emotional or psychological abuse
Other
Please rate the frequency of the following symptoms you have experienced in the past month:
*
Rows
Never
Rarely
Sometimes
Often
Always
Sleep disturbances
1
2
3
4
5
Flashbacks or intrusive memories
6
7
8
9
10
Difficulty concentrating
11
12
13
14
15
Feeling anxious or on edge
16
17
18
19
20
Avoiding reminders of the event
21
22
23
24
25
Please indicate your current level of distress related to the traumatic event(s):
*
No distress
1
2
3
4
5
6
7
8
9
Extreme distress
10
1 is No distress, 10 is Extreme distress
How much has the trauma affected your daily life?
*
Not at all
A little
Moderately
Severely
Have you sought support or professional help for your trauma?
*
Yes
No
If yes, what type of support have you received? (Select all that apply)
Therapy or counseling
Support from family/friends
Medication
Online resources/support groups
Other
Is there anything else you would like to share about your experience or needs?
Submit Assessment
Should be Empty: