TEC Client Name* First Last Client Date of Birth* MM slash DD slash YYYY Today's Date* MM slash DD slash YYYY 1. Have you been in a serious accident, where you could have been badly hurt or could have been killed?* Yes No 2. Have you seen a serious accident, where someone could have been (or was) badly hurt or died?* Yes No 3. Have you thought that you or someone you know would get badly hurt during a natural disaster such as a hurricane, flood, or earthquake?* Yes No 4. Has anyone close to you been very sick or injured?* Yes No 5. Has anyone close to you died?* Yes No 6. Have you had a serious illness or injury, or had to be rushed to the hospital?* Yes No 7. Have you had to be separated from your parent or someone you depend on for more than a few days when you didn't want to be?* Yes No 8. Have you been attacked by a dog or other animal?* Yes No 9. Has anyone told you they were going to hurt you?* Yes No 10. Have you seen someone else being told they were going to be hurt?* Yes No 11. Have you yourself been slapped, punched, or hit by someone?* Yes No 12. Have you seen someone else being slapped, punched, or hit by someone?* Yes No 13. Have you been beaten up?* Yes No 14. Have you seen someone else getting beated up?* Yes No 15. Have you seen someone being attacked or stabbed with a knife?* Yes No 16. Have you seen someone pointing a real gun at someone else?* Yes No 17. Have you seen someone else being shot at or shot with a real gun?* Yes No 18. Have you ever seen something else that was very scary or where you thought somebody might get hurt or die?* Yes No What was it?
