Please read all instructions carefully and answer the questions as accurately as possible. There are no right or wrong answers, just select the answer that best applies to your lived experiences.

First Name
Mobile Number

The following questions will ask you to identify and provide basic details regarding events you may have experienced that were stressful or traumatic.


How should you determine the number of traumas you have suffered?
Some traumas are isolated events, like a car accident or the loss of a loved one. For some, you have to use your intuition as to how to differentiate between traumas if necessary. In implementing our therapy we have found that even though one person may have hurt someone many times in the past, our brains tend to generalize the events into one basic trauma. So please count abuse from each person as one separate trauma. You may count multiple events from one time or place in your life if they seem to group together in your imagination. Just go with what you feel. 

Have you experienced more than one traumatic event?

Which type of difficult or stressful event(s) did you experience?

At what age did the/these event(s) occur?

What was the longest amount of time you were exposed to a single stressful event?

The following questions ask about your previous experiences with therapy or other mental health services. If the subsequent questions do not apply to you, please select "Not Applicable" and move forward.

Have you ever participated in therapy to work through the specific event(s) you have disclosed above?

How many sessions did you participate in?

Did you find this therapy improved your symptoms and/or overall mental health?

Have you ever been prescribed medications for anxiety, depression, insomnia or PTSD?

In the last month, have you experienced any of the following events? Please indicate to what degree by selecting the most appropriate answer.

1. Repeated, disturbing memories, thoughts, or images of the stressful experience?

3. Suddenly acting or feeling as if the stressful experience were happening again (as if you were reliving it)?

4. Feeling very upset when something reminded you of the stressful experience?

5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?

Avoiding memories, thoughts, or feelings related to the stressful experience?

7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?

9. Loss of interest in activities that you used to enjoy?

12. Feeling as if your future will somehow be cut short?

13. Trouble falling or staying asleep?

14. Irritable behavior, angry outbursts, or acting aggressively?

17. Feeling jumpy or easily startled?

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