• Whitehorse
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Section 1

Kids sometimes have different feelings and ideas. This form lists the feelings and ideas in groups. From each group of three sentences, pick one sentence that describes you best for the past two weeks. After you pick a sentence from the first group, go on to the next group. There is no right or wrong answer. Just pick the sentence that best describes the way you have been recently. Here is an example of how this form works. Try it. Select the sentence that describes you best.
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Section 2

People may have stressful events happen to them. Read the list of stressful things below and select YES for each of them that have EVER happened TO YOU. Circle NO if it has never happened to you. Do not include things you may have only heard about from other people or from the TV, radio, news, or the movies. Only answer what has happened to you in real life. Some questions ask about what you SAW happen to someone else. And other questions ask about what actually happened to YOU.
Sample:

Have you EVER gone to a basketball game? (Select YES or NO)

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Have you been in a serious accident, where you could have been badly hurt or could have been killed?

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Have you seen a serious accident, where someone could have been (or was) badly hurt or died?

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Have you thought that you or someone you know would get badly hurt during a natural disaster such as a hurricane, flood, or earthquake?

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Has anyone close to you been very sick or injured?

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Has anyone close to you died?

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Have you had a serious illness or injury, or had to be rushed to the hospital?

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Have you had to be separated from your parent or someone you depend on for more than a few days when you didn't want to be?

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Have you been attacked by a dog or other animal?

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Has anyone told you they were going to hurt you?

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Have you seen someone else being told they were going to be hurt?

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Have you yourself been slapped, punched, or hit by someone?

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Have you seen someone else being slapped, punched, or hit by someone?

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Have you been beaten up?

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Have you seen someone else getting beaten up?

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Have you seen someone else being attacked or stabbed with a knife?

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Have you seen someone pointing a real gun at someone else?

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Have you seen someone else being shot at or shot with a real gun?

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Section 3

You have just read a list of stressful events that might have happened to you. Some people have had these experiences and some people have not. Please think about the ones you answered YES to and pick the one that bothers you most. If there is some other stressful event that was not on the list, you can write that. It could have happened to you at anytime and it still bothers you NOW.

The thing that bothers me most is

Section 4

Below is a list of problems that kids sometimes have after experiencing something scary like we just looked at. Of all the experiences we just looked at, think of the thing that bothered you the most. Now these next questions ask about the thing that bothered you the most (whether it was getting hit, beaten up, threatened or anything else). Listen carefully and select the word that best describes how often these problems have bothered you IN THE PAST MONTH.

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Have you had upsetting thoughts or images about the event that came into your head when you didn't want them to?

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Have you had bad dreams or nightmares?

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Have you been acting or feeling as if the event was happening again (for example, hearing something or seeing a picture about it and feeling as if you were there again)?

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Have you been feeling upset when you think about or hear about the event (for example, feeling scared, angry, sad, guilty, etc.)?

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Have you had feelings in your body when you think about or hear about the event (for example, breaking out in a sweat, heart beating fast)?

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Have you been trying not to think about, talk about, or have feelings about the event?

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Have you been trying to avoid activities, people, or places that remind you of the event (for example, not wanting to play outside or go to school)?

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Have you not been able to remember an important part of the event?

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Have you had much less interest or not wanting to do things you used to do?

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Have you not felt close to people around you?

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Have you not been able to have strong feelings (for example, being unable to feel very happy)?

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Have you been feeling as if your future plans or hopes will not come true (for example, you will not have a job or getting married or have kids or go to high school)?

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Have you had trouble falling or staying asleep?

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Have you been feeling irritable or having fits of anger?

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Have you had trouble concentrating (for example, losing track of a story on television, forgetting what you read, not paying attention in class)?

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Have you been overly careful (for example, checking to see who is around you and what is around you)?

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Have you been jumpy or easily startled (for example, when someone walks up behind you)?

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Section 5

Is there anything else you would like to tell us?

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