Child PTSD Symptom Scale (CPSS-V) Child 20210512 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 you feel about the upsetting things you described. Choose the response that best describes how often that problem has bothered you IN THE LAST MONTH.1. Having upsetting thoughts or pictures about it that came into your head when you 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 you are 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 you 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 your body when you remember 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 reminds you 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 yourself, 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 your 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 you 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 your 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 yourself (for example, taking drugs, drinking alcohol, running away, cutting yourself.)* 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 you and what is around you)* 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 you, when you 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 you 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
