CPSS-V Caregiver Report

Client Name*

First Last

Client Date of Birth*

Today's Date*

These questions ask about how your child feels about the upsetting things you described. Select the response that best describes how often that problem has bothered him/her IN THE LAST MONTH

1. Having upsetting thoughts or pictures about it that came into your child's head when he/she 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 he/she was 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 he/she 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 his/her body when he/she remembers 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 remind him/her 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 himself/herself, 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 his/her 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 he/she 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 his/her 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 himself/herself (for example, taking drugs, drinking alcohol, running away, cutting himself/herself.)*

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 him/her and what is around him/her.)*

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 him/her, when he/she 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 he/she 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) Caregiver

These questions ask about how your child feels about the upsetting things you described. Select the response that best describes how often that problem has bothered him/her IN THE LAST MONTH

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