May Dugan Center Client Health Outcomes / Trauma Recovery Survey Client Name: _______________________ Case #: _________ Initial

6 Months

Annual

Survey Date: ________________

Termination

Choose the answer that best represents your experiences during the last six months.

I. Symptom Management 1. How often do you: Feel anxious Feel fearful Feel worthless Feel irritable Feel suspicious of others Feel depressed Have difficulty controlling your anger Have thoughts of suicide Hear voices 2. If you are prescribed medication, do you take it as prescribed? II. Daily Living 3. Are you satisfied with the way you spend your time? 4. My housing situation is: (Circle all that apply)

Never

Sometimes

Often

Always

Never

Sometimes

Often

Always

Shelter

With family or friends

By myself, with significant other and/or children

Homeless

Yes

5.

Is your housing stable?

6.

Are you satisfied with your housing?

7.

In the past 6 months, have you had any of the following: (Check all that apply) Psychiatric Hospitalization

Hospitalizations for medical reasons In jail, prison or arrested III. Recovery and Empowerment 8. I can take care of my symptoms before they get worse. 9.

I take care of medical problems.

10.

I have control over what happens in my life.

Revised: July 2016

Never Sometimes

No

Often

Always

IV. Have you ever experienced or witnessed (as a victim) any of the following? Put an “X” in each “yes” or “no” box.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Traumatic Life Experiences Adult physical assault Adult sexual assault Adults sexually abused as children Arson

Yes No 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

Bullying (verbal, cyber or physical)

Burglary Child physical abuse or neglect Child pornography Child sexual abuse / assault Domestic and / or family violence DUI / DWI incidents Elder abuse or neglect Hate crime (please describe):

Traumatic Life Experiences Human trafficking (labor) Human trafficking (sexual)

Yes No

Identity theft / Fraud / Financial crime

Kidnapping (non-custodial) Kidnapping (custodial) Mass violence (domestic / int’l) Car accident (i.e. hit / run) Robbery Stalking / harassment Survivor of homicide victim Teen Dating Victimization Terrorism (domestic / int’l)

26. Violation of a court protective order

V. Recovery Scale Directions: Place a mark on the line (0-100%) that best represents your experiences during the last week.

1. I make it through the day without thinking of upsetting memories of past events. 0%

50%

100% of the time

50%

100% of the time

2. I sleep free from nightmares. 0%

3. I am able to stay in control when I think of difficult memories. 0%

50%

100% of the time

4. I do the things that I used to avoid (e.g. daily activities, social activities, thoughts of events and people connected with past events). 0%

50%

100% of the time

50%

100% of the time

50%

100% of the time

5. I am safe. 0%

6. I feel safe. 0%

7. I have supportive relationships in my life. 0%

50%

100% of the time

8. I find that I can now safely feel a full range of emotions. 0%

50%

100% of the time

9. I can allow things to happen in my surroundings without needing to control them. 0%

50%

100% of the time

10. I am able to concentrate on thoughts of my choice. 0%

50%

100% of the time

11. I have a sense of hope about the future. 0%

50%

100% of the time

TOTAL