PTSD FORM

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PTSD FORM

This test will help our psychologist determine if you are dealing with PTSD and how we can help.

Email *

Sometimes things happen to people that are unusually or especially frightening, - horrible, or traumatic.
For example:
- a serious accident or fire
- a physical or sexual assault or abuse
- an earthquake or flood
- a war
- seeing someone be killed or seriously injured
- having a loved one die through homicide or suicide.

Have you ever experienced any of the events described above? *

Yes

If YES - please answer the questions below. In the past month, have you ...

1. Had nightmares about the event(s) or thought about the event(s) when you did not want to? *

Yes

2. Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)? *

Yes

3. Been constantly on guard, watchful, or easily startled? *

Yes

4. Felt numb or detached from people, activities, or your surroundings? *

Yes

Would you like our psychologist to contact you after this test for further evaluation and free mental health services? We provide FREE counselling services to members of the community with emotional, sexual, behavioural or any psychological issues, through either on one or group therapy sessions. *

Yes

If you answered yes above, please provide a phone number we can reach you on.

Thank you for taking the test.

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