Child and Adolescent Trauma Screen-Caregiver (CATS-C)

Child and Adolescent Trauma Screen-Caregiver (CATS-C) - 3-6 Years
Client's Name [your child's name]

First NameLast Name
Date of birth

MonthDayYear
Date
Name of caregiver completing this form

First NameLast Name
Relationship of person to child
In what setting do you receive services? check all that apply:

Phoenix OfficeLaveen OfficeTucson OfficeCottonwood OfficeTelehealth/RemoteIn HomeIn SchoolIn FacilityOther
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.

YesNo
2. Serious accident or injury like a car/bike crash, dog bite, sports injury.

YesNo
3. Robbed by threat, force or weapon

YesNo
4. Slapped, punched, or beat up in your family

YesNo
5. Slapped, punched, or beat up by someone not in the family

YesNo
6. Seeing someone in the family get slapped, punched or beat up.

YesNo
7. Seeing someone in the community get slapped, punched

YesNo
Type a question*

YesNo
8. Someone older touching his/her private parts when they shouldn’t.

YesNo
9. Someone forcing or pressuring sex, or when s/he couldn’t say no.*

YesNo
10. Someone close to the child dying suddenly or violently*

YesNo
11. Attacked, stabbed, shot at or hurt badly

YesNo
12. Seeing someone attacked, stabbed, shot at, hurt badly or killed

YesNoOther
13. Stressful or scary medical procedure.

YesNo
14. Being around war

YesNo
15. Other stressful or scary event?*

YesNo
If you answered yes to question 15, please describe:
Which one is bothering the child the most now?
Mark 0, 1, 2 or 3 for how often the following things have bothered the child in the last two weeks. Answer the best you can: 0 Never / 1 Once in a while / 2 Half the time / 3 Almost always:
1. Upsetting thoughts or images about a stressful event. Or re-enacting a stressful event in play.

0123
2. Having bad dreams related to a stressful event.

0123
3. Acting, playing or feeling as if a stressful event is happening right now.

0123
4. Feeling very emotionally upset when reminded of a stressful event.

0123
5. Strong physical reactions when reminded of a stressful event (sweating, heart beating fast).

0123
6. Trying not to remember, think about or have feelings about a stressful event.

0123
7. Avoiding anything that is a reminder of a stressful event (activities, people, places, things, talks)

0123
8. Increase in negative emotional states (afraid, angry, guilty, ashamed, confusion).

0123
9. Losing interest in activities s/he enjoyed before a stressful event. Including not playing as much.

0123
10. Acting socially withdrawn.

0123
11. Reduction in showing positive feelings (being happy, having loving feelings).*

0123
12. Being irritable. Or having angry outbursts without a good reason and taking it out on other people or things.*

0123
13. Being overly alert or on guard.*

0123
14. Being jumpy or easily startled.*

0123
15. Problems with concentration.*

0123
16. Trouble falling or staying asleep.

0123
Total Score
Score Meaning

Please mark YES or NO if the problems you marked interfered with:

	Yes	No
1. Getting along with others
2. Hobbies/Fun
3. School or daycare
4. Family relationships
5. General happiness

Reference

chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://istss.org/getattachment/Clinical-Resources/Child-Trauma-Assessments/Child-and-Adolescent-Trauma-Screen-(CATS)/CATS-Pre-School-3-6.pdf?lang=en-US
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Child and Adolescent Trauma Screen-Caregiver (CATS-C) - 3-6 Years

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.

Mark 0, 1, 2 or 3 for how often the following things have bothered the child in the last two weeks. Answer the best you can: 0 Never / 1 Once in a while / 2 Half the time / 3 Almost always: