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Complex PTSD Comprehensive Assessment Questionnaire

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Introduction

This questionnaire is designed to assess symptoms of Complex Trauma. By completing this form, we will be able to better understand any repeating traumatic experiences that may be affecting your mental and emotional well-being and standing in the way of your happiness. This assessment is not a diagnosis but rather a guide that provides valuable insights to help refine our therapeutic approach and create a customized plan tailored to your most important needs and goals.

Please take your time with each question and answer as honestly and openly as you can. There are no right or wrong answers—just your experience, which is valuable and important.

I look forward to our time together.

Warmly,

Monika

Monika Grace, CCTP-II
Integrative Somatic Psychotherapist, Trauma Specialist, EMDR, IFS, SE, PSYCH-K
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What is your full name?

What is your email?

What is your location?

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Instructions
This short form contains 30 questions across important categories including Trauma Exposure and Intrusive Symptoms, Avoidance and Numbing, Arousal and Hypervigilance, Disturbances in Self-Organization, Somatic Symptoms and CPTSD Impact on Daily Functioning.
Please read each statement carefully and choose the number that best reflects your experience during childhood. There are no right or wrong answers. Your responses will help in understanding areas that may need attention and healing.
For each question, select the response that most accurately reflects how frequently you have experienced the symptom in the last month. Use the following scale to answer:
Rating Scale:
1 = Never
2 = Rarely
3 = Sometimes
4 = Often
5 = Very Often

Trauma Exposure and Intrusive Symptoms

1. Have you experienced trauma that involved being in danger or feeling helpless, such as physical, emotional, or sexual abuse?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

2. Do you frequently have distressing memories or flashbacks of traumatic events?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

3. Do you often have nightmares or disturbing dreams related to your traumatic experiences?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

4. Do you experience intense emotional reactions when something reminds you of your trauma (e.g., crying, anger, anxiety)?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

5. Do you have a strong desire to avoid situations, people, or places that remind you of your trauma?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

Avoidance and Numbing

6. Do you often feel emotionally numb or disconnected from your feelings?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

7. Do you tend to avoid talking about the traumatic event(s) or avoid certain thoughts related to it?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

8. Have you lost interest in activities you once enjoyed or have difficulty experiencing pleasure?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

9. Do you withdraw from social interactions or find it difficult to connect with others emotionally?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

10. Do you experience difficulty in remembering important details about the traumatic event(s)?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

Arousal and Hypervigilance

11. Do you find it hard to relax or feel on edge most of the time?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

12. Are you easily startled by loud noises or unexpected events?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

13. Do you experience difficulty concentrating, especially when you are feeling stressed or triggered?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

14. Do you experience irritability or anger outbursts that are difficult to control?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

15. Do you have difficulty sleeping, such as staying asleep or waking up frequently?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

16. Do you feel constantly "on alert" or like something bad is going to happen?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

Disturbances in Self-Organization

17. Do you often feel like you're "not good enough" or that you lack worth as a person?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

18. Do you frequently experience feelings of shame, guilt, or self-blame related to your trauma?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

19. Do you have difficulty trusting others, even close friends or family members?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

20. Do you feel disconnected from your sense of identity, or as if you're "not the person you used to be"?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

21. Do you experience difficulties in regulating your emotions (e.g., feeling overwhelmed, sad, or angry without warning)?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

22. Do you have a negative self-image or experience persistent feelings of unworthiness?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

23. Do you often feel hopeless about the future or like there’s no way out of your current situation?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

24. Do you experience difficulties in maintaining intimate relationships (e.g., due to fear of rejection or feeling unworthy of love)?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

Somatic Symptoms

25. Do you experience unexplained physical symptoms like tension, headaches, or gastrointestinal issues when you’re feeling stressed or triggered?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

26. Do you feel detached from your body or experience dissociation during stressful situations?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

27. Do you experience physical responses to trauma reminders, such as sweating, shaking, or rapid heartbeats?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

CPTSD Impact on Daily Functioning

28. Do you find it difficult to function in daily activities, such as work, school, or personal care, because of your trauma-related symptoms?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

29. Do you have trouble maintaining healthy relationships because of your trauma (e.g., social withdrawal, emotional detachment)?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often

30. Are you often preoccupied with your trauma, making it difficult to focus on your daily responsibilities or goals?

In the past month, how often have you had repeated, disturbing, and unwanted memories of a traumatic event?
NeverVery often
Thank you for completing this questionnaire. Your responses will be discussed during your next session to identify areas for support and healing.
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