Youth Questionnaire
Feeling Traumatized or Triggered?
Name
First Name
Last Name
Do I have symptoms of re-living the traumatic event?
Do I have bad dreams or nightmares about the event or something similar?
Am I behaving or feeling as if the event were actually happening all over again?
Am I having a lot of emotional feelings when I am reminded of the event?
Do I feel safe where I live? Do I feel safe at school/work?
Please rank your concerns in the following areas on a scale of 1 to 10 (0 = No problems and 10 = Major problems). You may use the same number for more than one area
Anger
Depression
Anxiety
School
Suicidal Thoughts
Parents
Check symptoms you currently experience or have experienced
Headaches
Restlessness
Diziness
Pain
Excessive anger
Less need for sleep
Excess energy
Racing thoughts
Feeling Irritable
Feeling wired
Mood swings
Loss of appetite
Weight gain
Weight loss
Loss of appetite
Difficultly staying asleep
Frequent nightmares
Low energy
Unable to have fun
Feeling worthless
Feeling hopeless
Feeling isolated
Suicidal Thoughts
Crying Frequently
Frequent Worrying
Fears
Panic Attacks
Concentration Problems
Feel others are plotting against you
Constant suspicion or distrust
Hearing voices that others do not hear
Seeing things others do not see
Abuse
Family Conflict
Have you ever seen a counselor before?
Yes
No
What are some of your hobbies or things you do for fun?
What else would you like me to know
Date
-
Month
-
Day
Year
Date
Submit
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