Trauma history Stress Solutions of New York / Apex Counseling Trauma History Form Name(Required) First Last Parental abuse to one another(Required) Verbal Physical Not Applicable Parental abuse to self(Required) Verbal Physical Not Applicable Parental abuse to one siblings(Required) Verbal Physical Not Applicable Sexual abuse(Required)Familial separations(Required) Mother & Father Self Not Applicable Relationship & your age at time(Required)Family relocations & your age at time(Required)School related problems(Required) Victim of Bullying Berated by Teachers Not Applicable Hospitalizations(Required)Surgeries(Required)Job related problems(Required)Interpersonal problems with spouse or significant othersMotor vehicle accidents(Required)Other accidents(Required)Other problems(Required) Intrusive Memories Flashblacks Avoidance Behaviors Sleep disturbance(Required) Falling asleep Shortened sleep Interrupted sleep Excessive sleep
