Trauma Screening

PSS-I-5–Informed Screening for ART/RTM.

This screening is designed to help identify trauma-related symptoms and guide whether trauma-focused therapy could be beneficial. It is not a diagnosis.

Full name Address Email address Phone

PTSD & Trauma Screening (PSS-I-5–Informed)

This screening is informational and not a diagnosis. It helps determine whether trauma-focused therapy could be beneficial.

Trauma exposure (check all that apply) I directly experienced the event I witnessed the event I learned it happened to a close family member or friend I had repeated or intense exposure to distressing details

Have you experienced an event like this? Yes No

Most distressing trauma (brief description)

Did this event involve (check all that apply) Actual or threatened death Actual or threatened serious injury Actual or threatened sexual violence

Approximate date or timeframe of the event

Symptom frequency (past month)

0 = Not at all · 1 = Once a week or less · 2 = 2–3 times/week · 3 = 4–5 times/week · 4 = 6+ times/week

Re-experiencing symptoms Unwanted, distressing memories Disturbing dreams or nightmares Feeling as if the trauma were happening again Strong emotional distress when reminded Physical reactions when reminded

Avoidance symptoms Avoiding thoughts, memories, or feelings Avoiding activities, places, or situations

Changes in mood & thinking Difficulty remembering important parts of the trauma Negative beliefs about yourself, others, or the world Blaming yourself or others Strong negative emotions Loss of interest in activities Feeling detached or disconnected Difficulty experiencing positive emotions

Increased arousal & reactivity Irritability or aggressive behavior Risk-taking or self-destructive behaviors Feeling constantly alert or on guard Being easily startled or jumpy Difficulty concentrating Difficulty falling or staying asleep

Distress & functioning Overall distress Interference with daily life

Symptom onset & duration How long after the trauma did difficulties begin? How long have you experienced these difficulties?

This screening tool is for informational and educational purposes only and does not provide a medical or mental health diagnosis. Results should be reviewed with a licensed mental health professional. If you are experiencing thoughts of harming yourself or others, please contact emergency services or a crisis hotline immediately.

What happens next

We review your screening within 1–2 business days.
You’ll receive a response about next steps and scheduling.
All information is kept confidential.