Mental Health Questionnaire

What is Complex PTSD and Do I Have It?

Anonymous questionnaire
This 5 minute survey is completely anonymous. Produced by Recovery Code X CIC in partnership with Developwise CIC.

If you answer 'yes' to the questions below, you may be suffering from Complex PTSD. Help is available. Contact your GP for further information.

If you are struggling to complete this questionnaire, please contact info@developwise.co.uk or telephone 0753464327 for assistance.
1. Have you been a victim of any of the following? Please TICK relevant box(es).*

Childhood abuse/neglectDomestic violenceRacismBullyingExploitation/groomingTraffickingHomelessnessTortureOther
2. Where do you live? Please state the name of your town or city.*
3. What is your gender?*

MaleFemaleOr do you describe yourself in another way? (Write in gender identity in the comments box below.)
My gender identity is:

4. You are always monitoring your surroundings and find it hard to relax. *

	Strongly agree	Agree	Neither disagree nor agree	Disagree	Strongly disagree
Please TICK relevant box.

5. You avoid certain people or places that remind you of bad experiences or you avoid talking to anyone about your experiences. *

	A lot	Often	Sometimes	Rarely	Not at all
Please TICK relevant box.

6. Certain places, people and situations make you feel overwhelmed and it's hard to control your emotions. It can be frightening as you feel helpless or sick when it happens.*

	A lot	Often	Sometimes	Rarely	Not at all
Please TICK relevant box

7. Please TICK those that you recognise in yourself over the past two weeks.*

	Not At All	Sometimes	More than Half the Days	Nearly Every Day
Low mood or depression
Outbursts of anger
Self-hatred
Self-destructive behaviour
Risk-taking
Feelings of shame
Feelings of self-blame and distrust
Feel disconnected from yourself and the world (Dissociated)
Problems with intimacy
Difficulties experiencing pleasure, satisfaction, fun

8. If you checked off any problems, how difficult have those problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at allSomewhat difficultVery difficultExtremely difficult

	Please TICK relevant boxes
Yes - a women's group
Yes - a men's group
Yes - a mixed gender group
Yes - other group
No
Maybe
Don't know
Must be free of charge
I am willing to pay
Online group
Face-to-face group in my area
Would like to find out more

10. If you answered YES to the above, how frequently would you like to attend the group?
11. Please provide comments below.
Thank you for completing this questionnaire.

Please click on the Submit button below.
Should be Empty:

What is Complex PTSD and Do I Have It?

Thank you for completing this questionnaire.