Childhood Trauma Survey

A reflective survey that invites adults to describe childhood experiences of abuse or hardship, the support they sought, and how those experiences continue to shape their well-being today.

Use this template

Can You Describe Your Childhood Experience?

Did You Experience Any Form of Abuse During Your Childhood?

Yes No

If Yes, Please Specify the Type of Abuse (Physical, Emotional, Sexual, Neglect)

Have You Sought Professional Help to Address Your Childhood Trauma?

Yes No

If Yes, What Type of Therapy or Treatment Did You Receive?

Do You Feel That Your Childhood Trauma Has Impacted Your Adult Life?

Yes No

If Yes, Please Describe How It Has Impacted Your Life

What Coping Mechanisms Have You Developed to Deal With the Effects of Childhood Trauma?

Have You Disclosed Your Childhood Trauma to Anyone?

Yes No

If Yes, Who Have You Disclosed It to and What Was Their Response?

How Has Your Childhood Trauma Affected Your Relationships With Others?

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Childhood Trauma Survey

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