CPSS-V Child

Client Name*

First Last

Client Date of Birth*

Today's Date*

These questions ask about how you feel about the upsetting things you described. Choose the response that best describes how often that problem has bothered you IN THE LAST MONTH.

1. Having upsetting thoughts or pictures about it that came into your head when you didn't want them to.*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
6 or more times a week/almost always

2. Having bad dreams or nightmares.*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
6 or more times a week/almost always

3. Acting or feeling as if it was happening again (seeing or hearing something and feeling as if you are there again.)*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
6 or more times a week/almost always

4. Feeling upset when you remember what happened (for example, feeling scared, angry, sad, guilty, confused.)*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
6 or more times a week/almost always

5. Having feelings in your body when you remember what happened (for example, sweating, heart beating fast, stomach, or head hurting.)*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
6 or more times a week/almost always

6. Trying not to think about it or have feelings about it.*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
6 or more times a week/almost always

7. Trying to stay away from anything that reminds you of what happened (for example, people, places, or conversations about it.)*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
6 or more times a week/almost always

8. Not being able to remember an important part of what happened.*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
6 or more times a week/almost always

9. Having bad thoughts about yourself, other people, or the world (for example, "I can't do anything right", "All people are bad", "The world is a scary place.")*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
6 or more times a week/almost always

10. Thinking that what happened is your fault (for example, "I should have known better", "I shouldn't have done that", "I deserved that.")*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
6 or more times a week/almost always

11. Having strong bad feelings (like fear, anger, guilt, or shame.)*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
6 or more times a week/almost always

12. Having much less interest in doing things you used to do.*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
6 or more times a week/almost always

13. Not feeling close to your friends or family or not wanting to be around them.*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
6 or more times a week/almost always

14. Trouble having good feelings (like happiness or love) or trouble having any feelings at all.*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
6 or more times a week/almost always

15. Getting angry easily (for example, yelling, hitting others, throwing things.)*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
6 or more times a week

16. Doing things that might hurt yourself (for example, taking drugs, drinking alcohol, running away, cutting yourself.)*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
6 or more times a week/almost always

17. Being very careful or on the lookout for danger (for example, checking to see who is around you and what is around you)*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
6 or more times a week/almost always

18. Being jumpy or easily scared (for example, when someone walks up behind you, when you hear a loud noise.)*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
Nearly every day for 2 weeks

19. Having trouble paying attention (for example, losing track of a story on TV, forgetting what you read, unable to pay attention in class.)*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
6 or more days a week/almost always

20. Having trouble falling or staying asleep.*

Not at all
Once a week or less/a little
2 to 3 times a week/somewhat
4 to 5 times a week/a lot
6 more times a week/almost always

Child PTSD Symptom Scale (CPSS-V) Child

These questions ask about how you feel about the upsetting things you described. Choose the response that best describes how often that problem has bothered you IN THE LAST MONTH.

Please click SUBMIT when complete