Check all symptoms that apply to you *

I can't tell anyone about my past trauma or hurt.

There are details about the trauma or event that I cannot remember.

I have lost interest in things I used to love since the traumatic event.

I often feel angry and irritable.

I have difficulty maintaining relationships.

I use alcohol, drugs, or prescription medications oncer per week or more.

I find that I am repeating the same mistakes in life.

I avoid people, places, and things that remind me of my grief or trauma.

I have nightmares or flashbacks of the event.

I struggle with feelings of worthlessness, unworthiness, or dirtiness much of the time.

I have a difficulty trusting people or being intimate with anyone.

I find myself clinging to people too easily and too quickly.

I find myself pushing other people away so I do not develop an emotional attachment.

I put the responsibility on myself for what happened.

Name *

First Name

Last Name

Phone

(###)

###

####