INTRODUCTION:

We are collecting information about childhood trauma. We are doing this to learn what needs there might be in our area, and what we can do to help. We do not need you to put your name on this form. Your answers are anonymous and will be used to improve the services we offer. The survey should take about 15 minutes to complete.

We truly appreciate your insight and your time. If you have any questions, please contact us at equipttherapy@gmail.com
EVENTS:

Sometimes, scary or very upsetting things happen to people. These things can sometimes affect what we think, how we feel, and what we do.
1. Has your child ever seen people pushing, hitting, throwing things at each other, or stabbing, shooting, or trying to hurt each other?
2. Has someone ever really hurt your child? Hit, punched, or kicked them really hard with hands, belts, or other objects, or tried to hurt them physically in any way?
3. Has someone ever touched your child on the parts of their body that a bathing suit covers, in a way that made you or your child uncomfortable? Or has someone had your child touch them in that way?
4. Has anything else very upsetting or scary happened to your child (loved one died, separated from loved one, been left alone for a long time, not had enough food to eat, serious accident or illness, fire, dog bite, bullying)? What was it?
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REACTIONS:

Sometimes scary or upsetting events affect how people think, feel, and act. The next questions ask how your child has been feeling and thinking recently. How often did each of these happen in the last 30 days?
5. Your child has strong feelings in their body when they remember something that happened (sweating, heart beats fast, feel sick).
6. Your child tries to stay away from people, places, or things that remind them about something that happened.
7. Your child has trouble feeling happy or has other emotional difficulties.
8. Your child has trouble sleeping.
9. It’s hard for your child to concentrate or pay attention, or they have problems at school.
10. Your child feels alone and not close to people around them.
11. Your child has issues with eating, weight or their body.
12. Your child engages in self-destructive or risky behaviour, such as hurting themselves or taking drugs.
13. If your child has any issues related to the questions above, what kind of support would you find helpful?
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14. Where would you prefer this support to take place?
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15. Have you or your child had or tried to get help with this issue before
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17. Please tell us the gender of your child
18. Please tell us the ethnicity of your child
  • Asian or Asian British
  • Black, Black British, Caribbean or African
  • Mixed or multiple ethnic groups
  • White
  • Other ethnic group