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Childhood Trauma Survey

Page One

Thank you for your willingness to take this survey. This will help others to find ways of overcoming their childhood trauma. Over 4 million children experience trauma each year. Some may never overcome the trauma. Others will overcome the trauma and will not be affected in anyway. The purpose of this survey is to better understand how some were able to get over the trauma and what (or who) helped them to overcome it.

Your candid responses are greatly appreciated. It will be used to help others and will be totally confidential. If you are willing to participate in a phone interview with those conducting the study, please indicate your willingness at the end of this survey. If you would like to receive the results of the survey, please note that and leave an email address where we can send you the results.

Thank you again for your willingness to help others deal with childhood trauma.
1. There are many types of Childhood Trauma. Please check the box or boxes which describe the type of trauma that personally affected you.
2. What age did the trauma occur? (Please select all that apply.)
3. How long did the trauma occur?
4. What ended the trauma? *This question is required.
5. Who, if anyone, was very important in helping you overcome your trauma?
6. Who, in anyone, has been helpful to you as an adult?
8. Who, if anyone, still makes it hard for you to overcome the trauma?
9. How does the trauma still affect you now?
10. To what degree have you overcome the trauma?
Severely AffectedNo Longer Affected
11. Rank your current happiness.
Very HappyHappyNeutralUnhappyVery Unhappy
12. Rank your current level of anxiety.
Extreme AnxietyNo Anxiety
13. How often do you experience panic attacks?
19. How often do you remember the trauma?
The next set of questions are facts about yourself.
This question requires a valid number format.
23. What is your gender?
24. What is your marital status?
25. What is your sexual orientation?
26. If you are working, what best matches your job title?
27. What is your household income?
29. Do you attend church?
30. Would you consider yourself:
Please rate how you perceive yourself in the following questions.
31. How would you rate your attractiveness?
Very AttractiveSomewhat AttractiveNeutralSomewhat UnattractiveVery Unattractive
32. How would you rate your intelligence?
Above AverageSomewhat Above AverageAverageSomewhat Below AverageBelow Average
33. How kind are you?
Very KindAverageUnkindUnsure
34. How successful would you rate yourself in business?
Very SuccessfulSuccessfulNeutralUnsuccessfulVery Unsuccessful
35. How would you rate your success in relationships?
Very SatisfiedSatisfiedNeutralDissatisfiedVery DissatisfiedNot Applicable
36. How would you rate your child-rearing abilities?
Very SatisfiedSatisfiedNeutralDissatisfiedVery DissatisfiedNot Applicable
This question requires a valid email address.
This question requires a valid email address.
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