AV2 C3 - Trauma-Based Ministry

E-mail Address: *

Age:

Date of Birth

Race *

African American
Biracial
Caucasian
Native American
Asian/Pacific Islander
Spanish
Other
Unknown

Marital Status *

Married
Single
Divorced

Currently Able to Work? *

Yes
No

Have you been diagnosed with PTSD by a Physican or Phyciatrist? *

Yes
No

Any other current treatments at this time? Please explain *

Have you ever experienced, or witnessed, or been confronted with other traumatic events? Please explain *

Please list events, to the best of your knowledge, with events and dates. *

Not sure, see list *

Natural disaster (e.g. tornado, hurricane, fire or flood, earthquakes
Sesrious accident or serious injury
Combat or being in a combat zone
Sudden life-threatening illness
Accidental death or murder of a close friend or family member
Suicide of a close friend or family member, or almost suicide
Being attacked with a gun, nife, or other weapons
Attacked without a weapon but with the intent to kill or seriously injure
Severely beaten (i.e. beating that left marks or bruises), or witnessing severe physical violence
Sexual abuse as a child or adolescent
Physical force or the treat of physical force leading to unwaned sexual contact
Rape or attempted rape
Aggravated assault
Dominated or controlled by parent/partner
Humilated to the point you wanted to die
Growing up, not validated, or loved, but treated as an animal

Which causes you the most distress or upsets you the most? *

Do you remember what you were thinking and feeling at the time? Please explain *

When it was happening, did you think you would be killed or seriously hurt? Please explain

Which one most often comes in your thoughts when you don't want to think about it? *

Which event upsets you the most? Please explain *

Which event were you most afraid? *

Do you remember what you were thinking and feeling at the time? When it was happening? *

During the time, did you feel helpless, horrified or terrified? *

Yes
No

If there was an assailant or perpetrator(s), who was it/who were they? *

Stranger
Acquaintance
Enemy
Terrorist
Friend
Parent
Sibling
Clery Member
Boyfriend/girlfriend
Husband/Wife/Partner
Organization
Authority Figure
Relative
Neighbor
Other
Unknown

Where did the trauma occur? *

Own Residence
Assailant's residence
Friend/relative's residence
Park, street, alley
Parking lot/garage
School
Institution
Battlefield
Public Place
Abandoned property
Car, bus, train, plan
Workplace
Other - please describe on next question

If a person involved, how do you feel about them? *

If a person, what would you want to do if you saw them? *

Did you receive any injuries that continued to cause or to be a problem for you? *

Yes
No

Other where trauma occured

Were you given medical attention? Was it helpful? Are you still under medical care for these injuries or problems? If none, type none. *

Has any criminal or legal action resulted from this trauma? What is the status of that now? If none, type none.

Who, if anyone do you blame for the occurence of the trauma? *

Myself
Assailant(s) or perpetrators
An organization
The government
Friends and acquaintance
The environment
Chance
Other (please describe on the next question)
None

Blame others (other) please explain. If none, type none *

How have you been feeling about the trauma? *

Guilty
Shamed
Angry
Other (please explain on next question)
None - don't have any feelings - numb

How have you been feeling and chose other, if not type in none *

How has your physical health been since the trauma? *

Good
Fair
Poor

What health problems, if any, are you having? if none, type none. *

How have your mood been since the trauma? If long ago: how has your mood been lately). Feel depressed or down, anxious? Are ou as interested in things as you usually are? *

Since the trauma, have you ever thought about taking your life or life not worth living, or thoughts about suicide? If yes, how often? *

Have you made any tempts to suicide since the traumatic event? *

Yes
No

Do you or did ever cut yourself, scratch or burn yourself or any type of self harming way. What do you do to harm yourself? *

Yes
No

Have you ever been hopitalized sinc the trauma for an emotional or nervous condition? *

Yes
No

If you have been hospitalized please explain what for and if not, type in none *

Prescription medications: Note specific meds and frequenacy of use, if none type in none *

Do you take street drug? (please note the type and frequency), if none, type in none *

Do you take over-the-counter medication(Note type type and frequency of use) if none type in none *

On average, about how many drinks containing alcohol do you have per day? Has your pattern of use changed since the trauma? IF yes, how so? if none, type in none. *

How do you feel about God since the trauma? Please explain *

Growing up: Did a parent or other adult in the household OFTEN . . . Swear at you, insult you, put you down, or humiliate you? *

Yes
No

Were you ever validated or valued growing up? *

Yes
No
Sometimes

Did a parent or other adult in the household OFTEN . . . Push, grab, slap, pull your hair, or throw something at you? OR EVER hit you so hard that you had bruises, marks, or were injured? *

Yes
No

Did an adult or person at least 5 years older than you EVER . . . Touch or fondle you or have you touch their body in a sexual way? OR Try to or actually have oral, anal, or vaginal sex with you? *

Yes
No

Did you OFTEN feel that . . . No one in your family loved you or thought you were important or special? OR Your family didn’t look out for each other, feel close to each other, or support each other? *

Yes
No

Did you OFTEN feel that . . . You didn’t have enough to eat, had to wear dirty clothes, and had no on to protect you? OR Your parents were too intoxicated to care for you or take you to a doctor if you needed it? *

Yes
No

Were your parents EVER separated or divorced? *

Yes
No

Did you EVER live with anyone who was a problem drinker, an alcoholic, or used drugs? *

Yes
No

Has a household member EVER been depressed, mentally ill, or attempted suicide? *

Yes
No

Has a household member EVER been arrested, gone to jail, or been in prison? *

Yes
No

Over the last two weeks, Feeling nervous, anxious, or on edge *

Not at all
Several days
More than half the the days
Nearly every day

Over the last two weeks, not being able to stop or control worrying *