CAP Trauma History Questionnaire (THQ) Assessment

Assessment Details

Assessment Date

Client ID

Staff Name

Assessment done by:

Caregiver

Child

Adult

Caregiver Instructions

I’m going to ask you about different experiences your child may have had. Please think about things that may have happened to your child in addition to the experience that brought you here today.

Caregiver Questions/Responses

	Yes	No
1. Has your child ever been in or seen a serious accident?
2. Has someone close to your child ever been very sick or very hurt or injured?
3. Has your child ever experienced a severe illness or injury?
4. Has your child ever experienced a painful or scary medical treatment either when they were injured or sick?
5. Has your child ever experienced the death of someone close to him/her?
6. Has your child ever been unexpectedly separated from you (caregiver) or another person significant in the child’s life?
7. Has someone close to your child ever attempted or committed suicide or harmed him/herself?
8. Has your child ever been physically hurt (e.g., hit, kicked, punched) or threatened to be hurt?
9. Has someone ever robbed from your child? Or has your child ever witnessed this?
10. Has your child ever been attacked by a dog or other animal?
11. Has your child ever seen or heard a family member(s) physically fighting, attacking (e.g., pushing, hitting, punching, or using weapons) or beating each other up or threatening to hurt one another?
12. Has your child ever seen or heard someone in your neighborhood or school attacking each other or beating each other up (e.g., pushing, hitting, punching, or using weapons) or threatening to hurt one another?
13. Has someone ever made your child watch or do something sexual (e.g., such as touching your child in a sexual way, touching your child’s private parts, making your child touch their private parts, or made your child watch someone else touch themselves in a sexual way?)
14. Has someone important to your child ever repeatedly told your child that s/he was no good, repeatedly yelled at your child in a scary way, or had someone threaten to abandon your child, leave your child, or send them away?
15. Has a peer ever bullied your child on the internet or in person (e.g., called him/her names, teased him/her, made up stories about him/her, repeatedly told him/her they were no good, excluded them or threatened to hurt him/her)?
16. Has your child ever had a time when s/he did not have enough food or a place to live?
17. Has there ever been a time in your child’s life when an adult wasn’t taking care of him/her? (e.g., when s/he didn’t get fed, didn’t have clothes to wear or when s/he weren’t taken to school or to the doctor when s/he needed to go?)
18. Has your child ever seen anyone in your home using drugs like smoking drugs (other than cigarettes) or using needles?
19. Has your child ever seen anyone in your home drink too much (get drunk)?
20. Has your child ever been exposed to a natural disaster (e.g., been in a really bad storm like a hurricane or tornado or in a fire, flood or earthquake)?
21. Has your child ever experienced man-made disaster (e.g., bombings, or another situation where somebody did something that hurt or killed a lot of people at the same time) or exposure to war?
22. Has your child ever witnessed a family member who was arrested, or had a family member in jail?
23. Have there been other very scary or upsetting things that have happened to your child?

Instructions to be read to child

I’m going to ask about different experiences you may have had. Please think about things that may have happened to you in addition to the experience that brought you here today.

Sometimes, scary or very upsetting things happen to people. Some people have had some of these experiences, and some people have not had these experiences. I am going to read off a list of things that may have happened to you in the past. I’d like to ask you to tell me if any of these things have happened to you, and if so, when.

Child Questions/Responses

	Yes	No
1. Have you ever been in, or seen, a serious accident?
2. Has someone close to you ever been really sick or really hurt or injured?
3. Have you ever been really sick or really hurt or injured?
4. Have you ever experienced a painful or scary medical treatment, either when you were hurt or sick?
5. Has someone close to you ever died?
6. Have you ever been unexpectedly separated from someone who takes care of you or someone who is close to you?
7. Has someone close to you ever tried to hurt him/herself, or even tried to kill him/herself?
8. Has someone ever physically hurt you (e.g., hit, kicked or punched), or threatened to hurt you?
9. Have you ever been robbed, or seen someone you care about get robbed?
10. Have you ever been attacked by a dog or other animal?
11. Have you ever seen or heard people in your family physically fighting, attacking or beating each other up (e.g., pushing, hitting, punching or using weapons) or threatening to hurt each other?
12. Have you ever seen or heard someone in your neighborhood or school attacking each other or getting beaten up (e.g., pushing, hitting, punching or using weapons) or threatening to hurt each other?
13. Has anyone ever made you watch or do something sexual(e.g., touching you in a sexual way, touching your private parts, making you see or touch their private parts, or making you watch them touch their own private parts?)
14. Has a caregiver or anyone important to you repeatedly told you were no good, repeatedly yelled at you in a scary way, or threatened to abandon you, leave you, or send you away?
15. Has a peer ever bullied you on the internet or in person (e.g., called you names, teased you, made up stories about you, repeatedly told you were no good, excluded you or threatened to hurt you)?
16. Have you ever had a time in your life when you and your family did not have enough food or a place to live?
17. Has there ever been a time in your life when an adult wasn’t taking care of you? (e.g., when your parents didn’t feed you, when you didn’t have clothes to wear or when you weren’t taken to school or to the doctor when you needed to go?)
18. Have you ever seen anyone in your home using drugs, like smoking drugs (other than cigarettes) or using needles?
19. Have you ever seen anyone in your home drink too much (get drunk)?
20. Have you ever been exposed to a natural disaster (e.g., been in a really bad storm like a hurricane or tornado or in a fire, flood or earthquake)?
21. Have you ever experienced man-made disaster (e.g., bombings, or another situation where somebody did something that hurt or killed a lot of people at the same time) or exposure to war?
22. Have you ever witnessed a family member who was arrested, or had a family member in jail?
23. Have there been other really scary or upsetting things that have happened to you?

Adult Instructions

I’m going to ask you about different experiences you may have had either as a child or as an adult.

Please think about things that have happened to you in your lifetime including the experience that brought you and your child here today.

Adult Questions/Responses

	Yes	No
1. Have you ever been in or seen a serious accident?
2. Has someone close to you ever been very sick or very hurt or injured?
3. Have you ever experienced a severe illness or injury?
4. Have you ever experienced a painful or frightening medical treatment either when you were injured or sick?
5. Have you ever experienced the death of someone close to you?
6. Have you ever been unexpectedly separated from a person who has been very significant in your life?
7. Has someone close to you ever attempted or committed suicide or harmed him/herself?
8. Have you ever been physically hurt (e.g., hit, kicked, punched) or threatened with being hurt, either as a child or as an adult?
9. Have you ever been robbed? Or have you ever witnessed a robbery?
10. Have you ever been attacked by a dog or other animal?
11. Have you ever seen or heard a family member(s) physically fighting, attacking (e.g., pushing, hitting, punching, or using weapons) or beating each other up or threatening to hurt one another?
12. Have you ever seen or heard anyone being attacked or engaged in a physical fight (e.g., pushing, hitting, punching, or using weapons) or threatening to hurt one another?
13. Has someone ever made you watch or do something sexual (e.g., such as touching you in a sexual way, touching your private parts, making you touch their private parts, or made you watch someone else touch themselves in a sexual way?)
14. Has someone important to you ever repeatedly told you that you were no good, repeatedly yelled at you in a frightening way, or threatened to abandon you or leave you?
15. Has there ever been a time when you did not have enough food or a place to live?
16. Was there ever a time in your childhood when an adult wasn’t taking care of you? (e.g. when you didn’t get fed, didn’t have clothes to wear or when you weren’t taken to school or to the doctor when you needed to go?)
17. As a child, did you ever see anyone in your home using drugs, like smoking drugs (other than cigarettes) or using needles?
18. As a child, did you ever see anyone in your home drink too much (get drunk?)
19. As an adult, are you currently living or have you lived with someone who has had problems with alcohol or drugs?
20. Have you ever been exposed to a natural disaster (e.g., been in a really bad storm like a hurricane or tornado or in a fire, flood, or earthquake)?
21. Have you ever experienced man-made disaster (e.g., bombings, or another situation where somebody did something that hurt or killed a lot of people at the same time) or exposure to war?
22. Have you ever witnessed a family member who was arrested, or had a family member in jail?
23. Have there been other very frightening or upsetting things that have happened to you, either as a child or as an adult?

Contact Information