Fuller Life System

Fuller Life System

T.R.A.U.M.A. ASSESSMENT
T.R.A.U.M.A. ASSESSMENT

Tragedies and Rejection causes Anger and Unforgiveness, which can lead to Mental Illness and Abuse.
A Fuller Life Strategist is one with the responsibility for the formulation and implementation of a strategy. Strategy generally involves setting goals, determining actions to achieve the goals, and mobilizing resources to execute the actions. A Fuller Life Strategist is a caveat of the Fuller Life System. The Mission of every Fuller Life Strategist is to implement the Fuller Life System to Re-Establish, Re-Affirm, and Re-Align the family educating on the effects of Tragedy, Rejection, Anger, Unforgiveness, Mental Illness, and Abuse (T.R.A.U.M.A.) as a result of Adverse Childhood Experiences (A.C.E.)
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Email
example@example.com
Gender:

MaleFemaleLesbianGayTransgender WomanTransgender ManCisgenger
Other Gender write here:
Race
Religious preferences
Marital Status:

MarriedSingleDivorced
If married, how many times?
Do you have children?(Yes/No)
If so, how many? and What are their ages?
What is your height, and weight?
Are you happy with your height, and weight?
Do you have any visible scars? If so, where are they located?
How is your financial stability? Do you owe a lot of debt? or any Student Loans?
Have you been diagnosed with a mental illness?(Yes/No) If so, when was you diagnosed?
Education:
Did you graduate High School?(Yes/No)
What is your highest level of education?
Are you employed? Yes __ No___ What type of work do you do?
Are you happy with your career?(Yes/No)
What is your relationship with your parents? Siblings?Spouse/significant other? Children?
TRAGEDY:
lamentable, dreadful, or fatal event or affair; calamity; disaster; In the Performing
Arts genre, tragedy can be defined as a dramatic composition, often in verse, dealing with a serious or somber theme, typically involving a great person destined to experience downfall or utter destruction, as through a character flaw or conflict with some overpowering force, as fate or an unyielding society.
CO-VID 19:
Have you tested positive for CO-VID 19 or know someone who has tested positive?
How has the CO-VID 19 pandemic affected you emotionally?
How has the CO-VID 19 pandemic affected your financially?
How has the CO-VID 19 pandemic affected your job experience?
How has the CO-VID 19 pandemic affected your educational arrangement with your child(ren)?
Explain how the CO-VID 19 experience affected your relationship with friends, boyfriend/girlfriend, fiancé, spouse, family members?
Have you lost anyone in your family or know anyone who transitioned due to CO-VID 19? If so, who?
SEXUAL
Have you experienced any type of sexual abuse while growing up through result of rape, incest, molestation (fondling, touching, penetration)?

FriendAcquaintanceIntimate RelationshipFamily Member
Have you reported it to anyone? If yes, then who? If no, then why?
What happened to your perpetrator that committed the act against you?
A: Living? If yes, explain how you feel.
B: Do they live in the same city? If yes, what is the distance? If no, where do they live?
B: Deceased? If yes, how do you feel that they transitioned? If yes, did they pass due to natural causes, illness, or a traumatic experience?
What would you say/do if you saw your perpetrator?
DEATH
Do you know anyone who has transitioned? If yes, then who?
Did they transition due to natural causes, and/or unexpectedly, through illness, or due to a traumatic event?
In what way(s) did their transition impacted your life?
What stage of grief are you in? Depression, Anger, Bargaining, Depression, or Acceptance
RACISM
Have you ever experienced any form of individual and/or systematic racism in the community,workplace, sexism?
If yes, explain.
Have you ever been passed over a position at work with the necessary credentials or credentials that exceed the position and were not hired for the job without any explanation?
In your own words, describe what it is like to live as a person of color.
POLICE BRUTALITY
How do you feel about the police?
What lesson(s) were you taught by your parent(s), grandparent(s), and/or authoritative figure about the police?
Have you ever been stopped by the police without any explanation or felt harassed without any reasonable explanation?
3. If yes, describe your experience.
4. Have you felt scared or feared for your life when stopped by the police?
5. Have you ever been racially profiled by the police?
6. Do you know anyone that has died at the hands as evidence of a false police report or the victim of police brutality?
7. Do you know someone who was the victim of murder?

Gang Violence?Domestic Violence?Suicided?Police Brutality?
8. How many funerals have you attended in the past 3 months? 6 months? 9 months? Year? Life?Have you attended a funeral as evidence of violence?
9. How have you dealt with the tragedy(ies) that you have experienced?
POVERTY
Affluenza was used during a sentencing phase by a psychologist who testified that the then 16-year-old Ethan Couch was a product of "affluenza" -- a term he used to describe Couch's irresponsible lifestyle associated with his affluent upbringing of his parents. Couch drunken driving accident killed four people and injured several others. This term was made up to lessen the sentencing of a teenager who did not take responsibility for his actions. If being born with a silver spoon in your mouth causes you the inability to make wise decisions, then what type of decisions are made living in poverty?
1. Has your personal and family life been affected by poverty?
2. If yes, explain.
3. How has your community been affected by poverty?
4. Does living in poverty affect your ability to make sober decisions?
5. Explain how your past and present decisions were affected by poverty.
6. Does your paycheck leave you with a surplus left over until the next paycheck?
7. Do you attempt to save but find yourself tapping into your savings account to cover a bill oran overdraft?
8. Are you privy to the same information and amenities to those that are not living in poverty?
9. Do you know someone who died suddenly and/or unexpectedly? (Yes/No)
10. Did the person(s) die because of an illness? (Yes/No)
11. Do you know someone who died because of murder?

Gang ViolenceDomestic ViolenceSuicided
12. How many funerals have you attended in the past ___6 months? ___9 months? _____Year
13. How have you dealt with the tragedy or tragedies that you have experienced?
REJECTION:

The spurning (to refuse or accept something or someone because you feel that thing or person is not worth having) of a person’s affections.
1. Do/Did you know your biological parent(s)? Yes __ No___
2. Were you rejected from a biological parent(s)? Yes __ No___ Did your parents raised you? Yes____No____ If no who did?
3. What were the circumstances surrounding your birth?

A. One Night Stand?B. Had an affair with a married man/woman?C. Unwanted sex of the child from the parent?D. Abortion?E. Were you rejected by a boyfriend/girlfriend?F. Child(ren)?G. Stepchildren?H. At school and from who?
4. Were you rejected by the people in the church through clergy or other people in the church?
5. Were you rejected from a supervisor? (Yes /No)
6. Were you rejected from receiving a position at your employer?
7. How has being rejected affect your relationship with the same sex?
8. How has being rejected affected your relationship with the opposite sex?
9. How has being rejected affected your marriage?
10. How has being rejected affected your ability to parent?
11. How has being rejected affected your ability to be a good employee?
12. Explain your rejection(s).
ANGER: (n): a strong feeling of annoyance, displeasure, or hostility
1. Who are you angry with?
2. Do you think you have an anger problem?
3. What is the reason for your anger?
3. How has your anger affected your life?
4. How has your anger affected your relationship with others?
5. On a scale of 1-10, 1 lowest, 10 highest, how much has anger affected your relationship with others?
6. What would cause you to refrain from anger?
7. Has your anger caused you to say hurtful words to the person that you are angry with?(Yes/No)
8. Has your anger caused you to regret what you said to the person that you were angry withafter you calmed down?(Yes/No)
9. Has your anger caused you to destroy property?(Yes/No)
10. Has your anger caused you to get in trouble with the law?
11. How do you deal with your anger?
UNFORGIVENESS:

(The act of not releasing a debt or transgression against you)
1. Who do you need to forgive?
2. What would cause you to forgive?
3. What makes it difficult to forgive?
4. What must happen for you to forgive?
5. How has unforgiveness affected your friendships?
6. How has unforgiveness affected your relationships with family?
7. How has the lack of forgiveness affected the quality of your marriage?
8. What has unforgiveness cost you?
9. Do you need an apology from the person that hurt you to forgive them?
10. How has unforgiveness affected your emotions?
11. How has unforgiveness disturbed your peace?
MENTAL ILLNESS: syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.
(Psychology Today)
Insanity (noun): the condition of being seriously mentally ill.
Madness (Mental Illness): the state of being mentally ill, or unable to behave in a reasonable way.
Paranoia: a strong tendency to feel that you cannot trust other people or that other people have a bad opinion of you, or unreasonable false belief.
Depression: a type of mental illness that causes long periods of prolonged Unhappiness: anger turned inward.
1. Does mental illness run in your family?(Yes/No)
2. Have you been diagnosed with a mental illness?(Yes/No)
3. Are you in denial that you may have a mental illness? Yes __ No___
4. Do you take any psychotropic medication(s)? Yes __ No___
5. Have you ever been hospitalized due to mental illness? Yes __ No___
6. How have you educated yourself on your mental illness?
7. Do you feel like others treat you differently because of your diagnosis? Yes __ No___
ABUSE:

to treat someone cruelly or violently
Psychological: form of abuse, characterized by a person subjecting or exposing another person to behavior that may result in psychological trauma, including anxiety, chronic depression, or post-traumatic stress disorder.
Emotional: (Emotion): a conscious mental reaction (such as anger or fear) subjectively experienced as strong feeling usually directed toward a specific object; (E+ energy) in motion.
Physical: An act of another party involving contact intended to cause feelings of physical pain.
injury, or other physical suffering or bodily harm
Substance: Use of illegal or legal regular harmful drugs.
PHYSICAL ABUSE
1. Have you ever been physically abused? Yes __ No___If yes, who?
2. How many times were you physically abused?
3. Have you ever been slapped, punched, kicked, shaken by a parent, family member,boyfriend/girlfriend, spouse, etc.? Yes __ No___
4. At what age did you experience physical abuse?
5. How were you affected by being physically abused?
6. If so, describe how physical abuse affected your self-esteem.
7. Describe your physical abuse.
EMOTIONAL/PSYCHOLOGICAL ABUSE
1. Were you emotionally/psychologically abused? Yes __ No___If yes, who?
2. How many times were you emotionally/psychologically abused?
3. At what age were you emotionally/psychologically abused?
4. How were you affected by being emotionally/psychologicallyabused?
5. If so, describe how physical abuse affected your self-esteem.
6. Describe your emotional/psychological abuse.
SUBSTANCE ABUSE
1. Have you ever used legal (Over the Counter) or illegal drugs and/or alcohol with the intentof easing or masking your pain? Yes __ No___
2. What was your drug(s) of choice?
3. Have you ever used drugs and/or alcohol recreationally? Yes __ No___
4. At what age did you use drugs?
5. How has substances affected your quality-of-life?
Should be Empty:

Now create your own Jotform - It's free!Create your own Jotform

Fuller Life System

T.R.A.U.M.A. ASSESSMENT

Education:

TRAGEDY:

CO-VID 19:

SEXUAL

DEATH

RACISM

POLICE BRUTALITY

POVERTY

REJECTION:

ANGER: (n): a strong feeling of annoyance, displeasure, or hostility

UNFORGIVENESS:

ABUSE:

PHYSICAL ABUSE

EMOTIONAL/PSYCHOLOGICAL ABUSE

SUBSTANCE ABUSE