Childhood Traumas

Childhood Trauma Worksheet

Trauma in the simplest terms, is trapped energy. It can be caused by numerous things and at the core of trauma is the emotional signature of shame. Most of recovery is intended to help us become honest and heal the traumas in our lives. Also, most of our traumas form repeating patterns so until we identify and heal each of them, we will continue to attract people, places and things that will trigger us. Please use this form to inventory your childhood traumas. This form includes the issues that are exposed in the ACES (Adverse Childhood Experience Questionnaire for Adults) test
Did you experience lack of any basic needs?

foodclean clothingshelterprivacyprotectionOther
Share what you can neglect of your basic needs
Did you lose a parent or caregiver?

deathdivorceabandonmentOther
Share what you can about the people you lost in childhood
Were you exposed to mental health issues?

mental illnessdepressionsuicidalOther
Share what you can about mental health issues in childhood
Did you live with addiction?

alcoholdrugsgamblingfoodhoardingspendingOther
Share what you can about addiction in your childhood
Did you live with adult domestic violence?

fightinghittingpunchingbeatingthreatsOther
Share what you can about domestic violence in your childhood
Did you live with anyone who went to jail or prison?

jailprisonhad to wear tetherhousehold arrestOther
Share what you can about jail / prison in your childhood
Did you experience verbal abuse from parents or caregivers?

swearingthreatsnamecallinggaslightinginsultsyellingOther
Share what you can about verbal abuse in your childhood
Did you experience physical abuse from adults in your home?

hittingkickingbeatingtorturecruel physical punishmentOther
Share what you can about physical abuse in your childhood
Were you made to feel bad by adults in your home?

worthlessunlovedunwanteda mistakea bad personflawedOther
Share what you can about emotional abuse in your childhood
Did you experience any sexual abuse in your home?

from parentsfrom relativesfrom siblingsfrom neighborsfrom strangersfrom friendsOther
Share what you can about sexual abuse in your childhood. *** Please note: we are not professionals and if your abuse was prolonged and or severe you may need the help of a specialist ***
Did you experience any religious abuse in your home?

forced beliefspunishment in the name of God or religionforced practicesOther
Share what you can about religious abuse in your childhood
Were you exposed to racism in your childhood?

by parents or caregiversby siblingsby people at schoolby strangersby youotherOther
Share what you can about racism in your childhood
Other forms of childhood trauma

unwanted or frequent movingabused, teased or bullied in schoolpovertyfatal or traumatic accidentsrandom violenceattacked or bitten by animalsexposed to adult situations or contentdangerous neighborhoods or atmosphereschronic illnessmedical issues, yours or someone elsesobesitygender identity issuesspeech problemsbedwettingshouting, screaming, slamming and fighting at homeshamed for any reasonOther
Share what you can about your additional childhood traumas
Who are you willing to speak with? (if other, add their name and email address)

Jeff RoundsSelyna BreezeOther
Name

First NameLast Name
Email
example@example.com
By submitting I hereby confirm that the information I have given above is true, and that I will be receiving an email response to my submission and an invitation to discuss the results with a nonprofessional member of Mixed Recovery.
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Childhood Trauma Worksheet