Trauma Screening Template

## What's Included

This Trauma Screening Template is designed to facilitate a comprehensive, structured assessment of trauma symptoms and history in clinical and mental health settings. It includes detailed sections for patient demographics, trauma exposure history, symptom checklists aligned with DSM-5 criteria for PTSD and related disorders, and risk assessment components such as safety and suicidality screening. Additional fields capture the duration, frequency, and impact of symptoms on daily functioning, providing a holistic view of the client’s trauma experience.

The template also incorporates standardized screening tools such as the Primary Care PTSD Screen (PC-PTSD-5) and space for clinician observations, clinical impressions, and initial treatment recommendations. Each section is clearly labeled and formatted for ease of use during intake or follow-up sessions, ensuring consistency and thoroughness in documentation.

## Who This Template Is For

This template is ideal for clinical psychologists, psychiatrists, licensed clinical social workers (LCSWs), marriage and family therapists (MFTs), counselors, and other mental health professionals who conduct trauma-focused assessments or integrate trauma screening into their diagnostic and treatment planning process.

## How to Use

Begin by collecting basic demographic and clinical history information from the client, ensuring all trauma exposure events are noted in detail. Use the symptom checklist section to systematically assess and document current trauma-related symptoms, using the standardized screening tools embedded within the template to guide questioning. Be sure to record any safety concerns or risk factors identified during the screening process.

Following the initial data entry, use the clinician observation and impression sections to summarize findings and formulate a preliminary diagnosis or referral plan. This template can be used during intake or periodic reevaluation sessions to track symptom progression or response to treatment. Always ensure documentation is clear, objective, and complies with your clinical agency’s standards.

## Customize with MentalNote

With MentalNote AI, you can automatically generate this Trauma Screening Template directly in Microsoft Word, customizing fields to match your specific clinical workflow and documentation preferences. MentalNote leverages natural language processing to tailor questions, symptom checklists, and clinical notes based on your input, streamlining the documentation process and improving accuracy in trauma assessment. This enables clinicians to spend less time on paperwork and more time focusing on client care.