CTS-5.26 COMPLEX TRAUMA SCREENING. 
The information you provide on this form is only handled by registered data controllers within Mabadiliko Intercultural Therapy CIC for GDPR compliance and your counsellor/therapist. (Under these circumstances a data controller can be either an individual practitioner and/or an organisation that is providing your 
counselling / psychotherapy).

This questionnaire is split into 2 main parts; Symptomatic categories and Additional considerations, to screen for Post-Traumatic Stress Disorder (PTSD) / Complex PTSD (CPTSD) using Criterion descriptors adapted from the DSM5.

The scores may or may not suggest an INDICATIVE Diagnosis – An indicative or preliminary diagnosis is used to adapt therapy treatment plans and is not a formal psychiatric diagnosis. The answers on this questionnaire and your overall score is used to support you with the management of your post traumatic experiences. This questionnaire should  be reviewed periodically (approximately every 4 sessions) to monitor your therapeutic progress.


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Email *
DATE FORM COMPLETED *
MM
/
DD
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YYYY
GENDER *
STAGE FORM COMPLETED  *
IMPORTANT - PLEASE READ

Thinking about your most traumatic experience/s, or the experience/s that trouble you the most, please score the symptoms as honestly as possible taking into account how you have been feeling over the past MONTH.
Please only select one scoring option per row when considering the symptomatic categories. 
The scoring options are: 
- Not at all 
- Rarely
- Sometimes
- Often

If you are using a phone, tablet or other small device you might find it useful to rotate your screen.
CATEGORY 1: 
INTRUSION (RE-EXPERIENCING)
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0 Not At All
1 Rarely
2 Sometimes
3 Often
Recurrent, unwanted or distressing memories, images or intrusive thoughts
Reliving the experience/s as if they were happening again (flashbacks and/or panic attacks)
Hearing the voice/s of the person or people associated with the traumatic experience/s when they are not present
Upsetting dreams or nightmares about the traumatic experience/s
Severe emotional distress or physical reactions that are disproportionate to the present situation
CATEGORY 2:
AVOIDANCE
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0 Not At All
1 Rarely
2 Sometimes
Often
Trying to avoid thinking or talking about the traumatic experience/s
Avoiding places, activities or people that are reminders of the traumatic experience/s
Self-induced isolation (purposefully keeping yourself to yourself)
Agoraphobic anxiety (avoiding going outside)
CATEGORY 3: 
COGNITION & MOOD
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0 Not At All
1 Rarely
2 Sometimes
3 Often
Feeling disconnected from your surroundings (dissociation)
Not remembering important aspects of the traumatic experience/s
Negative thoughts about yourself, other people or the world that causes you distress
Hopelessness about the future
Difficulty maintaining close relationships
Lack of interest in activities you once enjoyed
Difficulty experiencing positive emotions and/or feeling emotionally numb
Difficulty getting to sleep, staying asleep or experiencing insomnia
CATEGORY 4: 
CHANGES IN PHYSICAL & EMOTIONAL REACTIONS
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0 Not at all
1 Rarely
2 Sometimes
3 Often
Jumpy, easily startled or frightened
Always on guard for danger and/or intense fear of death or dying
Self-destructive or risky behaviour (any kind of behaviour that could be harmful for you)
Lack of concentration
Irritability, angry outbursts or aggressive behaviour
Overwhelming guilt or shame
CATEGORY 5: 
RISK
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0 Not At All
1 Rarely
2 Sometimes
3 Often
Thoughts you would be better off dead and/or plans to end your life
Suicidal attempts or behaviours
Self-harm / hurting yourself in any way
Please add up your scores and insert the total below
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Please select the appropriate range according to your score
 *
SEVERITY SCALE (Scores are evaluated using the following severity scale)
6 symptoms or more experienced over the past month, scored in the 2 and/or 3 range, in accordance to the following criteria is indicative of PTSD:
-  1 symptom from Intrusion category
-  1 symptom from Avoidance category
-  2 symptoms from Cognition & Mood category
-  2 symptoms from Arousal category

* 6 symptoms or more experienced over the past month, with the majority scored in the 1 range and the criteria above is not met, indicates pre-symptomatic or stabilised PTSD/CPTSD.

* Any marked C-PTSD indicators in addition to a PTSD indicative score, suggests an indicative diagnosis of C-PTSD.
CPTSD INDICATORS (Please check all that apply)
 *
Required
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