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The Zen Dylan Koh Fund
Who We Are
Our Solution
Take Action
Experience
Join Us
Get Connected
Book an Event
Share Your Story
Facts
Get Help
Talk To Someone
The Zen Dylan Koh Fund
Stories
Store
GIVE
Fundraise
Hope . Worth . Destiny
Name
*
First Name
Last Name
Stressful or scary events happen to many children. Below is a list of stressful and scary events that sometimes happen. Mark YES if it happened to the child to the best of your knowledge. Mark NO if it didn’t happen to the child.
1. Serious natural disaster like a flood, tornado, hurricane, earthquake, or fire.
*
Yes
No
2. Serious accident or injury like a car/bike crash, dog bite, or sports injury.
*
Yes
No
3. Threatened, hit or hurt badly within the family.
*
Yes
No
4. Threatened, hit or hurt badly in school or the community.
*
Yes
No
5. Attacked, stabbed, shot at or robbed by threat.
*
Yes
No
6. Seeing someone in the family threatened, hit or hurt badly.
*
Yes
No
7. Seeing someone in school or the community threatened, hit or hurt badly.
*
Yes
No
8. Someone doing sexual things to the child or making the child do sexual things to them when he/she couldn’t say no. Or when the child was forced or pressured.
*
Yes
No
9. On line or in social media, someone asking or pressuring the child to do something sexual. Like take or send pictures.
*
Yes
No
10. Someone bullying the child in person. Saying very mean things that scare him/her.
*
Yes
No
11. Someone bullying the child online. Saying very mean things that scare him/her.
*
Yes
No
12. Someone close to the child dying suddenly or violently.
*
Yes
No
13. Stressful or scary medical procedure.
*
Yes
No
14. Being around war.
*
Yes
No
Other stressful or scary event?
*
If yes, please describe the event.
This section is about all the scary or stressful events that happened to the child. Mark 0, 1, 2 or 3 for how often the following things have bothered the child in the last two weeks.
1. Upsetting thoughts or images about a stressful event. Or re-enacting a stressful event in play.
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
2. Bad dreams related to a stressful event.
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
3. Acting, playing or feeling as if a stressful event is happening right now.
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
4. Feeling very emotionally upset when reminded of a stressful event.
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
5. Strong physical reactions when reminded of a stressful event (sweating, heart beating fast).
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
6. Trying not to remember, talk about or have feelings about a stressful event.
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
7. Avoiding activities, people, places or things that are reminders of a stressful event.
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
8. Not being able to remember an important part of a stressful event.
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
9. Negative changes in how s/he thinks about self, others or the world after a stressful event.
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
10. Thinking a stressful event happened because s/he or someone else did something wrong or did not do enough to stop it.
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
11. Having very negative emotional states (afraid, angry, guilty, ashamed).
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
12. Losing interest in activities s/he enjoyed before a stressful event. Including not playing as much.
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
13. Feeling distant or cut off from people around her/him.
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
14. Not showing or reduced positive feelings (being happy, having loving feelings).
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
15. Being irritable. Or having angry outbursts without a good reason and taking it.
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
16. Risky behaviour or behaviour that could be harmful.
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
17. Being overly alert or on guard.
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
18. Being jumpy or easily startled.
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
19. Problems with concentration.
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
20. Trouble falling or staying asleep.
*
0 = Never
1 = Once in a while
2 = Half the time
3 = Almost always
TOTAL SCORE
*
CATS 7-17 Years Score <15 Normal. Not clinically elevated. CATS 7-17 Years Score 15-20 Moderate trauma-related distress. CATS 7-17 Years Score 21+ Probable PTSD.
Please mark “YES” or “NO” if the problems you marked interfered with:
1. Getting along with others
*
Yes
No
2. Hobbies/fun
*
Yes
No
3. School or work
*
Yes
No
4. Family relationships
*
Yes
No
5. General happiness
*
Yes
No
Thank you!
