ETM Form 1A
Sources of Psychological Trauma
Patient Name
Jointly Participating Primary Patient (e.g. CDP or CoDep Spouse

Information taken from:

  1. Patient interviews: notes/pgs                                                                                     N/A
  2. Psych/social data: pgs                                                                                                 N/A
  3. Network data: source(s)                                                                                               N/A
  4. Chemical dependency evaluations: pgs                                                                    N/A
  5. Testing: Intstruments & pgs:                                                                                      N/A
  6. ETM Psychtrauma Screen: Pgs                                                                                 N/A
Does this data indicate the existence of psychological trauma? Yes     No
  1. If not sure, return to non trauma related evaluation procedures until additional data becomes available
  2. If "no," end the ETM evaluation program
  3. If "yes," identify the sources of trauma and periods (age trauma occurred); register below
Sources                             Period Sources                             Period
1.  Chemical Dependency_________________
2.   Spouse Codependency________________
3.   Parent Codepency ___________________
4.   ACA Codepency ____________________
5.   Other Codepency ____________________
6.   Sexual Assault (single Incident) _________
7.   Sexual Assault (multiple) ______________
8.   Physical Assault (single) ______________
9.   Physical Assault (multiple) _____________
10. Death of a loved one (single) ___________
11. Death of a loved one (multiple) __________
12. Near Death of Self ____________________
13. Near Death of Loved One ______________		 14. Crisis Mgt. Job (Single) ____________________
15. Crisis Mgt. Job (Multiple) __________________
16. Combat (single) _________________________
17. Combat (multiple) ________________________
18. Injury: Crisis Mgt Job: ____________________
19. Associate's death: Crisis Mgt _______________
20. Causing death as a Job Function _____________
21. Personal Injury/Accident ___________________
22. Disease/Self _____________________________
23. Disease/Loved One _______________________
24. Natural Catastrophe _______________________
25. Perpetration of Violence ____________________
26. Other __________________________________
                 __________________________________
  1. If there is just one source of trauma, skip the next form (1B) and go directly to 2a, 3a, 3b.
  2. If there is more than one source of trauma, go to form (1B): "ETM Worksheet: Addressing Multiple Sources of Trauma."
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