Form TSCC_A

Name

Age

Se x

Identification No

Race

Never Some- Lots of Almost all
times times of the time

Date

Copyrighted Materials

1. Bad dreams or nightmares…………………………….................
2. Feeling afraid something bad might happen…………………….

0

1

2

3

0

1

2

3

3. Scary ideas or pictures just pop into my head…………………...

0

1

2

3

4. Pretending I am someone else…………………………………...

0

1

2

3

5. Arguing too much……………………………………..................

0

1

2

3

6. Feeling lonely ……………………………………………………

0

1

2

3

7. Feeling sad or unhappy………………………………..................

0

1

2

3

8. Remembering things that happened that I didn't like ……………

0

1

2

3

9. Going away in my mind, trying not think.....................................

0

1

2

3

10. Remembering scary things……………………………………..

0

1

2

3

2 = Lots of times

11. Wanting to yell and break things……………………………….

0

1

2

3

12. Crying…………………………………………………………..

3 = Almost all of the time

0

1

2

3

13. Getting scared all of a sudden and don't know why……………

0

1

2

3

14. Getting mad and can't calm down……………………………...

0

1

2

3

15. Feeling dizzy...............................................................................

0

1

2

3

16. Wanting to yell at people……………………………………….

0

1

2

3

17. Wanting to hurt myself................................................................

0

1

2

3

18. Wanting to hurt other people…………………………………...

0

1

2

3

19. Feeling scared of men…………………………………………..

0

1

2

3

20. Feeling scared of women…………………………….................

0

1

2

3

21. Washing myself because I feel dirty on the inside…………......

0

1

2

3

22. Feeling stupid or bad…………………………………………...

0

1

2

3

23. Feeling like I did something wrong…………………………….

0

1

2

3

24. Feeling like things aren't real…………………………………...

0

1

2

3

25. Forgetting things, can't remember things....................................

0

1

2

3

26. Feeling like I'm not in my body………………………. ……….

0

1

2

3

27. Feeling nervous or jumpy inside…………………….................

0

1

2

3

28. Feeling afraid…………………………………………………...

0

1

2

3

29. Can't stop thinking about something bad that happened to me...

0

1

2

3

0 = Never

30. Getting into fights………………………………………………

0

1

2

3

31. Feeling mean...............................................................................

1 = Sometimes

0

1

2

3

32. Pretending I'm somewhere else………………...........................

0

1

2

3

2 = Lots of times

33. Being afraid of the dark………………………………………...

0

1

2

3

34. Worrying about things………………………………………….

3 = Almost all of the time

0

1

2

3

35. Feeling like nobody likes me......................................................

0

1

2

3

36. Remembering things I don't want to remember……………….

0

1

2

3

37. My mind going empty or blank………………………………..

0

1

2

3

38. Feeling like I hate people............................................................

0

1

2

3

39. Trying not to have any feelings………………………………...

0

1

2

3

40. Feeling mad.................................................................................

0

1

2

3

41. Feeling afraid somebody will kill me…………………………..

0

1

2

3

42. Wishing bad things had never happened……………………….

0

1

2

3

43. Wanting to kill myself………………………………………….

0

1

2

3

0 = Never
1 = Sometimes

44. Daydreaming…………………………………………………...
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