Trauma Screening Questionnaire

We can help you if you…

Feel stuck and unable to move forwards

Have flashbacks or painful past memories that don’t seem to fade

Negative thoughts or moods associated with the event

To help us understand how to help you, please can you kindly fill out the information below:

Please type in your name...

Please type in your contact number...

Which of the following you suffer from (Select more then one if needed):

Irritability or outbursts of anger

Feel overwhelmed and unable to cope

Negative beliefs about yourself, others the world and or cause or consequences of the event

Persistent negative state

Inability to feel positive emotions

Problems sleeping

Feel defensive or jumpy

Why is it important for you to overcome this?

What will be the benefits if you do?

What is stopping you?

Free Text

How can the MindCoach help you? 

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