PSSI-5 for coaches/counselors data collection for research Coach Name* Coach's Email* Coach's Phone NumberClient ID* Client Name* Client Phone Number*Client Email* Client Race* Client Age* Gender* Male Female Client Occupation*9-11 SurvivorActive Duty ArmyActive Duty NavyActive Duty USMCActive Duty Air ForceActive Duty Coast GuardArmy VeteranNavy VeteranAir Force VeteranMarine VeteranCoast Guard VeteranNational GuardMilitary ReservesLaw EnforcementLaw Enforcement Officer/Army VeteranLaw Enforcement Officer/USMC VeteranLaw Enforcement Officer/Air Force VeteranLaw Enforcement Officer/Navy VeteranLaw Enforcement Officer/Coast Guard VeteranFirefighterParamedicFirefighter-ParamedicFirefighter-Paramedic/Army VeteranFirefighter-Paramedic/USMC VeteranFirefighter-Paramedic/Air Force VeteranFirefighter-Paramedic/Navy VeteranFirefighter-Paramedic/Coast Guard VeteranCorrectionsCrime Scene TechnicianFederal Bureau of Prisons911 DispatcherDoctorNurseMental Health CounselorTeacherCilvilianOtherTrauma Type*AbortionAccidental DeathAct of TerrorismArrestBirth TraumaBullyingCatastrophic DiagnosisChild AbuseChild NeglectChildhood Sexual AssaultClergy AbuseCombatCrime Victim (other than Sexual Trauma)Death of SpouseDivorceDomestic ViolenceGun ViolenceHuman TraffickingLine of Duty (LEO)Line of Duty (Firefighter)Line of Duty (EMS)Line of Duty (Medical)Line of Duty (Corrections)Line of Duty (Federal)Medical TraumaMiscarriageMilitary Sexual TraumaNatural DisasterSexual AssaultSuicideTraffic CrashTraumatic GriefOther (If other, please specify below)Trauma Type (if other) This is a* Initial Evaluation Follow Up Evaluation Date of Initial/Follow Up Evaluation* YYYY dash MM dash DD PSSI5 Score* Number of Sessions (if final follow up) The scores are as follows: (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe Many people are exposed to a disturbing or traumatic event at some point in their lives. These experiences can happen in any of the following ways. Have you:1. Directly experiencing the event Yes No 2. Witnessing the event Yes No 3. Learning that the event happened to a close family member or close friend Yes No 4. Experiencing repeated or intense exposure to distressing details of the event (e.g. emergency workers collecting human remains) Yes No Examples of traumatic events include natural disasters, accidents, sexual assaults, physical assaults, combat, childhood sexual abuse, torture, or life-threatening illness. Did this event include:Actual or threatened death? Yes No 1. Have you had unwanted distressing memories about the trauma? (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe 2. Have you been having bad dreams or nightmares related to the trauma? (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe 3. Have you had the experience of feeling as if the trauma were actually happening again? (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe 4. Have you been very EMOTIONALLY upset when reminded of the trauma? (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe 5. Have you had PHYSICAL reactions when reminded of the trauma (e.g., sweating, heart racing)? (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe 6. Have you been making efforts to avoid thoughts or feelings related to the trauma? (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe 7. Have you been making efforts to avoid activities, situations, or places that remind you of the trauma or that feel more dangerous since the trauma? (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe 8. Are there any important parts of the trauma that you cannot remember? (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe 9. Have you been viewing yourself, others, or the world in a more negative way (e.g. “I can’t trust people,” “I’m a weak person”)? * (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe 10. Have you blamed yourself for the trauma or for what happened afterwards? Have you blamed others that did not directly cause the event for the trauma or what happened afterwards? (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe 11. Have you had intense negative feelings such as fear, horror, anger, guilt or shame? (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe 12. Have you lost interest in activities you used to do? (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe 13. Have you felt detached or cut off from others? (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe 14. Have you had difficulty experiencing positive feelings? (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe 15. Have you been acting more irritable or aggressive? (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe 16. Have you been taking more risks or doing things that might cause you or others harm (e.g., driving recklessly, taking drugs, having unprotected sex)? (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe 17. Have you been overly alert or on-guard (e.g., checking to see who is around you, etc.)? (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe 18. Have you been jumpier or more easily startled? (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe 19. Have you had difficulty concentrating? (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe 20. Have you had difficulty falling or staying asleep? (0) Not at all (1) Once a week or less/little (2) 2 to 3 times a week/somewhat (3) 4 to 5 times a week/very much (4) 6 or more a week/severe Total:CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
