PTSD Screening Assessment Form
Please complete this screening to help assess symptoms related to Post-Traumatic Stress Disorder (PTSD). Your responses are confidential and will be used solely for assessment purposes.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Have you experienced or witnessed a traumatic event in your life?
*
Yes
No
In the past month, how often have you experienced the following symptoms?
*
Rows
Not at all
Once or twice
A few times
Almost every day
Repeated, disturbing memories, thoughts, or images of a stressful experience?
1
2
3
4
Avoiding activities, places, or people that remind you of the traumatic event?
5
6
7
8
Feeling distant or cut off from other people?
9
10
11
12
Feeling irritable or having angry outbursts?
13
14
15
16
Having trouble falling or staying asleep?
17
18
19
20
Being 'super alert' or watchful on guard?
21
22
23
24
How would you rate the impact of these symptoms on your daily life?
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
Have you ever received a diagnosis of PTSD from a mental health professional?
Yes
No
Prefer not to say
Are you currently receiving any treatment for PTSD or other mental health conditions?
Yes
No
Prefer not to say
If you would like to share any additional information or concerns, please do so here:
Submit Assessment
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