Psychological Trauma Assessment Form
Use this form to gather information about trauma-related experiences, current symptoms, and daily impact for an assessment review. The form title must remain exactly "Psychological Trauma Assessment Form" everywhere it appears.
Assessment Overview
Name or Initials
*
Age Range
*
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Prefer not to say
Preferred Contact / Follow-up Method
Phone
Email
No follow-up needed
Prefer not to say
Trauma Exposure and Current Impact
Trauma exposure summary
*
Type of experience
*
Accident
Loss or bereavement
Violence or assault
Abuse
Natural disaster
Serious illness or injury
Witnessed harm to someone else
Other
When did it occur?
Current symptom severity
*
1
2
3
4
5
Current impact areas
*
Rows
Not at all
Mild
Moderate
Severe
Sleep
1
2
3
4
Mood
5
6
7
8
Concentration
9
10
11
12
Avoidance
13
14
15
16
Hypervigilance
17
18
19
20
Daily functioning
21
22
23
24
Support and Follow-up
Current Support Status
*
Has regular support
Has some support but inconsistent
Limited or no support
Prefer not to say
Notes or Additional Details
Submit Psychological Trauma Assessment Form
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