PTSD Assessment DSM-5 (PCL-5)

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Introduction

By completing this form, we will be able to better understand any 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?

Where are you located (city)?

Instructions

Please read each of the following questions carefully. Based on your experiences in the last month, please select the number that best describes how much you have been bothered by each symptom. Rating scale

1 = Not at all

2 = A little bit

3 = Moderately

4 = Quite a bit

5 = Extremely

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

2. In the past month, how often have you had upsetting dreams or nightmares related to a traumatic event?

3. In the past month, how often have you had flashbacks or felt as if you were reliving a traumatic event?

4. In the past month, how often have you felt upset or distressed when reminded of a traumatic event?

5. In the past month, how often have you experienced physical reactions (e.g., sweating, heart racing) when reminded of a traumatic event?

6. In the past month, how often have you avoided thoughts or feelings about a traumatic event?

7. In the past month, how often have you avoided external reminders (people, places, conversations) that remind you of a traumatic event?

8. In the past month, how often have you felt distant or emotionally numb from others?

9. In the past month, how often have you felt emotionally cut off or detached from others?

10. In the past month, how often have you felt like you have no positive emotions?

11. In the past month, how often have you felt irritable or angry?

12. In the past month, how often have you had trouble sleeping (e.g., trouble falling asleep, waking up during the night)?

13. In the past month, how often have you been startled or easily shocked by unexpected events?

14. In the past month, how often have you had difficulty concentrating or focusing on tasks?

15. In the past month, how often have you felt constantly on guard or hypervigilant (e.g., being easily startled, feeling tense)?

16. In the past month, how often have you felt that you were in danger or at risk of harm?

17. In the past month, how often have you felt that the future holds little or no hope?

18. In the past month, how often have you had difficulty trusting others?

19. In the past month, how often have you been avoiding places or people because of your past traumatic experiences?

20. In the past month, how often have you felt that your life is disrupted or affected by the memories or effects of the traumatic event(s)?

Thank you for completing the assessment. We appreciate your time and honesty. We will discuss your results during your sessions.

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