ITQ Form

About You

First Name

Last Name

To avoid processing errors please enter your full name as held on our database, i.e. the name we use when we contact you.

Introduction

Please identify the experience that troubles you most and answer the questions in relation to this experience.

Brief description of experience

When did the experience occur

PTSD Responses

Below are a number of problems that people sometimes report in response to traumatic or stressful life events. Please read each item carefully, then select one of the options to indicate how much you have been bothered by that problem in the past month.

1) Having upsetting dreams that replay part of the experience or are clearly related to the experience?

1) Any relevant notes on above

2) Having powerful images or memories that sometimes come into your mind in which you feel the experience is happening again in the here and now?

2) Any relevant notes on above

3) Avoiding internal reminders of the experience (for example, thoughts, feelings or physical sensations)?

3) Any relevant notes on above

4) Avoiding external reminders of the experience (for example, people, places, conversations, objects, activities or situations)?

4) Any relevant notes on above

5) Being super-alert, watchful or on guard?

5) Any relevant notes on above

6) Feeling jumpy or easily startled?

6) Any relevant notes on above

In the past month have the symptoms above...

7) Affected your relationships or social life?

7) Any relevant notes on above

8) Affected your work or ability to work?

8) Any relevant notes on above

9) Affected any other important part of your life such as parenting, or school or college work, or other important activities?

9) Any relevant notes on above

(Note: There is no question 10)

CPTSD Responses

Below are problems or symptoms that people who have had stressful or traumatic events sometimes experience. The questions refer to ways you typically feel, ways you typically think about yourself and ways you typically relate to others. Answer the following thinking about how true each statement is of you.

How true is this of you..?

11) When I am upset, it takes me a long time to calm down

11) Any relevant notes on above

12) I feel numb / emotionally shut down

12) Any relevant notes on above

13) I feel like a failure

13) Any relevant notes on above

14) I feel worthless

14) Any relevant notes on above

15) I feel distant or cut-off from people

15) Any relevant notes on above

16) I find it hard to stay emotionally close to people

16) Any relevant notes on above

In the past month, have the above problems in emotions, in beliefs about yourself and in relationships...

17) Created concern or distress about your relationships or social life?

17) Any relevant notes on above

18) Affected your work or ability to work?

18) Any relevant notes on above

19) Affected any other important part of your life such as parenting, or school or college work, or other important activities?

19) Any relevant notes on above

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