Client - Trauma Informed Care Quiz

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Before your 18th birthday, did a parent or other adult in the household often or very often… swear at you, insult you, put you down, or humiliate you? or act in a way that made you afraid that you might be physically hurt?* This field is required.

YESNO

4

Before your 18th birthday, did a parent or other adult in the household often or very often… push, grab, slap, or throw something at you? or ever hit you so hard that you had marks or were injured?* This field is required.

YESNO

5

Before your 18th birthday, did an adult or person at least five years older than you ever… touch or fondle you or have you touch their body in a sexual way? or attempt or actually have oral, anal, or vaginal intercourse with you?* This field is required.

YESNO

6

Before your eighteenth birthday, did you often or very 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?* This field is required.

YESNO

7

Before your 18th birthday, did you often or very often feel that… you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or your parents were too drunk or high to take care of you or take you to the doctor if you needed it?* This field is required.

YESNO

8

Before your 18th birthday, was a biological parent ever lost to you through divorce, abandonment, or other reason* This field is required.

YESNO

9

Before your 18th birthday, was your mother or stepmother: often or very often pushed, grabbed, slapped, or had something thrown at her? or sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?* This field is required.

YESNO

10

Before your 18th birthday, did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?* This field is required.

YESNO

11

Before your 18th birthday, was a household member depressed or mentally ill, or did a household member attempt suicide?* This field is required.

YESNO

12

Before your 18th birthday, did a household member go to prison?* This field is required.

YESNO

13

Results