PTSD Initial Screening Intake
Patient Information
Full Name
Date of Birth
Age
Gender
Female
Male
Other
Date of Intake
Presenting Concerns
Please describe the reason for this PTSD screening
History of Trauma
Type of trauma experienced
Date/Timeframe of trauma
Description of traumatic event(s)
Has this been previously discussed or treated?
Yes
No
Symptom Screening
Check symptoms currently experienced (select all that apply):
Re-experiencing (flashbacks, nightmares, intrusive thoughts)
Avoidance (avoiding reminders, people, places)
Hyperarousal (exaggerated startle, irritability, insomnia)
Persistent negative mood, thoughts, or emotions
Dissociation, detachment, numbness
Impact on Daily Life
Impact on work, school, relationships, daily functioning
Mental Health & Support
Current or past psychiatric diagnoses
Current medications
Support system (family, friends, community)
Risk Assessment
Thoughts of self-harm, suicide, or harming others
Clinician Notes