TEC Form – Child and Family Agency

Client Name*

First Last

Client Date of Birth*

Today's Date*

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

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

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

4. Has anyone close to you been very sick or injured?*

5. Has anyone close to you died?*

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

7. 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?*

8. Have you been attacked by a dog or other animal?*

9. Has anyone told you they were going to hurt you?*

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

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

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

13. Have you been beaten up?*

14. Have you seen someone else getting beated up?*

15. Have you seen someone being attacked or stabbed with a knife?*

16. Have you seen someone pointing a real gun at someone else?*

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

18. Have you ever seen something else that was very scary or where you thought somebody might get hurt or die?*

What was it?