Child PTSD Symptom Scale (CPSS-V) Caregiver 20210419 Client Name* First Last Client Date of Birth* MM slash DD slash YYYY Today's Date* MM slash DD slash YYYY These questions ask about how your child feels about the upsetting things you described. Select the response that best describes how often that problem has bothered him/her IN THE LAST MONTH1. Having upsetting thoughts or pictures about it that came into your child's head when he/she didn't want them to.* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot 6 or more times a week/almost always 2. Having bad dreams or nightmares.* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot 6 or more times a week/almost always 3. Acting or feeling as if it was happening again (seeing or hearing something and feeling as if he/she was there again.)* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot 6 or more times a week/almost always 4. Feeling upset when he/she remember what happened (for example, feeling scared, angry, sad, guilty, confused.)* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot 6 or more times a week/almost always 5. Having feelings in his/her body when he/she remembers what happened (for example, sweating, heart beating fast, stomach, or head hurting.)* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot 6 or more times a week/almost always 6. Trying not to think about it or have feelings about it.* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot 6 or more times a week/almost always 7. Trying to stay away from anything that remind him/her of what happened (for example, people, places, or conversations about it.)* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot 6 or more times a week/almost always 8. Not being able to remember an important part of what happened.* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot 6 or more times a week/almost always 9. Having bad thoughts about himself/herself, other people, or the world (for example, "I can't do anything right", "All people are bad", "The world is a scary place.")* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot 6 or more times a week/almost always 10. Thinking that what happened is his/her fault (for example, "I should have known better", "I shouldn't have done that", "I deserved that.")* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot 6 or more times a week/almost always 11. Having strong bad feelings (like fear, anger, guilt, or shame.)* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot 6 or more times a week/almost always 12. Having much less interest in doing things he/she used to do.* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot 6 or more times a week/almost always 13. Not feeling close to his/her friends or family or not wanting to be around them.* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot 6 or more times a week/almost always 14. Trouble having good feelings (like happiness or love) or trouble having any feelings at all.* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot 6 or more times a week/almost always 15. Getting angry easily (for example, yelling, hitting others, throwing things.)* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot 6 or more times a week 16. Doing things that might hurt himself/herself (for example, taking drugs, drinking alcohol, running away, cutting himself/herself.)* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot 6 or more times a week/almost always 17. Being very careful or on the lookout for danger (for example, checking to see who is around him/her and what is around him/her.)* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot 6 or more times a week/almost always 18. Being jumpy or easily scared (for example, when someone walks up behind him/her, when he/she hear a loud noise.)* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot Nearly every day for 2 weeks 19. Having trouble paying attention (for example, losing track of a story on TV, forgetting what he/she read, unable to pay attention in class.)* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot 6 or more days a week/almost always 20. Having trouble falling or staying asleep.* Not at all Once a week or less/a little 2 to 3 times a week/somewhat 4 to 5 times a week/a lot 6 more times a week/almost always Please click SUBMIT when complete
