Healthcare Trauma Questionnaire

HEALTHCARE TRAUMA QUESTIONNAIRE

Purpose: This questionnaire gathers clinical and safety information related to traumatic experiences and symptoms to inform assessment and treatment. All information provided will be treated as confidential except as required by law (including reporting of child or elder abuse, imminent risk of harm to self or others, or pursuant to a court order). Completion of this form is voluntary but assists the clinician in creating a safe and effective treatment plan.

Patient Information

Date of Birth:    Gender: Female Male Non-binary/Other

Emergency Contact

Insurance / Billing

Presenting Concern / Trauma Event

Date(s) of event(s):

Trauma History (Select all that apply)

Physical assault    Sexual assault    Serious accident    Medical trauma/procedure

Combat-related trauma    Childhood abuse/neglect    Witnessed violence    Natural disaster

Symptoms (Select all that apply)

Intrusive memories/flashbacks    Nightmares    Avoidance of reminders

Hypervigilance/startle response    Mood changes / irritability    Dissociation / numbing

Sleep disturbance    Difficulty concentrating    Increased substance use

Functional Impact

Have these symptoms affected: Work/School    Relationships    Sleep    Daily activities

Mental Health & Medical History

Substance Use

Alcohol:    Tobacco:

Safety Assessment

Are you currently experiencing thoughts of harming yourself? Yes No

Are you experiencing thoughts of harming others? Yes No

Treatment Preferences & Goals

Preferred treatment approaches: CBT Trauma-focused therapy Medication management Other

Authorization & Certification

By signing below, I certify that the information provided on this Healthcare Trauma Questionnaire is true and complete to the best of my knowledge. I understand that this information will be used for clinical assessment, treatment planning, coordination of care, and may be disclosed to other healthcare providers or insurers as necessary for treatment, payment, or healthcare operations when I authorize such disclosure. I acknowledge the limits of confidentiality, including mandatory reporting of suspected child or elder abuse, disclosure required to prevent imminent harm to self or others, and disclosures compelled by lawful process. I consent to the collection and use of the information contained herein for treatment purposes.

I authorize limited release of information as needed to coordinate care and billing.    I do not authorize release beyond direct treatment team.

I understand that I may withdraw this authorization at any time by providing written notice to the treating clinician, except to the extent that action has already been taken in reliance on this authorization. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by clinician-patient confidentiality.

I certify that I have read and understand the statements above and that I have had the opportunity to ask questions regarding the information collected and the limits of confidentiality.

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