Tian Dayton Trauma Survey
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WELCOME:

We are collecting data on ACOAs, can you please help us by taking an easy survey that is fun, informative and uplifting. We would so appreciate your participation!

We are exploring and quantifying both symptoms of relationship trauma and qualities of strength and resilience.

Instructions:
In the appropriate box, please indicate the degree that best corresponds to how much of each quality you feel you possess

1. How often do you experience any of the following?

Please rate frequency on a scale from 1 (never) to 4 (always)

	1	2	3	4	N/A
Problems with Self- Regulation	*WELCOME: We are collecting data on ACOAs, can you please help us by taking an easy survey that is fun, informative and uplifting. We would so appreciate your participation! We are exploring and quantifying both symptoms of relationship trauma and qualities of strength and resilience. Instructions: In the appropriate box, please indicate the degree that best corresponds to how much of each quality you feel you possess 1. How often do you experience any of the following? Please rate frequency on a scale from 1 (never) to 4 (always) Problems with Self- Regulation 1	Problems with Self- Regulation 2	Problems with Self- Regulation 3	Problems with Self- Regulation 4	Problems with Self- Regulation N/A
Hyper Vigilance/Anxiety	Hyper Vigilance/Anxiety 1	Hyper Vigilance/Anxiety 2	Hyper Vigilance/Anxiety 3	Hyper Vigilance/Anxiety 4	Hyper Vigilance/Anxiety N/A
Numbing of responsiveness/Emotional Constriction	Numbing of responsiveness/Emotional Constriction 1	Numbing of responsiveness/Emotional Constriction 2	Numbing of responsiveness/Emotional Constriction 3	Numbing of responsiveness/Emotional Constriction 4	Numbing of responsiveness/Emotional Constriction N/A
Somatic Disturbances: Body Aches and Pains	Somatic Disturbances: Body Aches and Pains 1	Somatic Disturbances: Body Aches and Pains 2	Somatic Disturbances: Body Aches and Pains 3	Somatic Disturbances: Body Aches and Pains 4	Somatic Disturbances: Body Aches and Pains N/A
Dissociation/Memory Disturbances	Dissociation/Memory Disturbances 1	Dissociation/Memory Disturbances 2	Dissociation/Memory Disturbances 3	Dissociation/Memory Disturbances 4	Dissociation/Memory Disturbances N/A
Learning Difficulties.	Learning Difficulties. 1	Learning Difficulties. 2	Learning Difficulties. 3	Learning Difficulties. 4	Learning Difficulties. N/A
Hyper-reactivity/Easily Triggered	Hyper-reactivity/Easily Triggered 1	Hyper-reactivity/Easily Triggered 2	Hyper-reactivity/Easily Triggered 3	Hyper-reactivity/Easily Triggered 4	Hyper-reactivity/Easily Triggered N/A
Intense emotional reactions and sleep problems	Intense emotional reactions and sleep problems 1	Intense emotional reactions and sleep problems 2	Intense emotional reactions and sleep problems 3	Intense emotional reactions and sleep problems 4	Intense emotional reactions and sleep problems N/A
Aggression against self and others	Aggression against self and others 1	Aggression against self and others 2	Aggression against self and others 3	Aggression against self and others 4	Aggression against self and others N/A
Learned Helplessness	Learned Helplessness 1	Learned Helplessness 2	Learned Helplessness 3	Learned Helplessness 4	Learned Helplessness N/A
Intrusive Re-experiencing	Intrusive Re-experiencing 1	Intrusive Re-experiencing 2	Intrusive Re-experiencing 3	Intrusive Re-experiencing 4	Intrusive Re-experiencing N/A
Desire to Self Medicate	Desire to Self Medicate 1	Desire to Self Medicate 2	Desire to Self Medicate 3	Desire to Self Medicate 4	Desire to Self Medicate N/A
Avoidance/Tendency to Isolate	Avoidance/Tendency to Isolate 1	Avoidance/Tendency to Isolate 2	Avoidance/Tendency to Isolate 3	Avoidance/Tendency to Isolate 4	Avoidance/Tendency to Isolate N/A
Unresolved Grief	Unresolved Grief 1	Unresolved Grief 2	Unresolved Grief 3	Unresolved Grief 4	Unresolved Grief N/A
Depression with Feelings of Despair	Depression with Feelings of Despair 1	Depression with Feelings of Despair 2	Depression with Feelings of Despair 3	Depression with Feelings of Despair 4	Depression with Feelings of Despair N/A
Survivor’s Guilt	Survivor’s Guilt 1	Survivor’s Guilt 2	Survivor’s Guilt 3	Survivor’s Guilt 4	Survivor’s Guilt N/A
Shame	Shame 1	Shame 2	Shame 3	Shame 4	Shame N/A
Loss of Trust and Faith	Loss of Trust and Faith 1	Loss of Trust and Faith 2	Loss of Trust and Faith 3	Loss of Trust and Faith 4	Loss of Trust and Faith N/A
Fused Feelings/Boundary Issues	Fused Feelings/Boundary Issues 1	Fused Feelings/Boundary Issues 2	Fused Feelings/Boundary Issues 3	Fused Feelings/Boundary Issues 4	Fused Feelings/Boundary Issues N/A
Distorted Reasoning (Stinkin’ Thinkin’)	Distorted Reasoning (Stinkin’ Thinkin’) 1	Distorted Reasoning (Stinkin’ Thinkin’) 2	Distorted Reasoning (Stinkin’ Thinkin’) 3	Distorted Reasoning (Stinkin’ Thinkin’) 4	Distorted Reasoning (Stinkin’ Thinkin’) N/A
Loss of Ability to Take in Caring and Support from Others	Loss of Ability to Take in Caring and Support from Others 1	Loss of Ability to Take in Caring and Support from Others 2	Loss of Ability to Take in Caring and Support from Others 3	Loss of Ability to Take in Caring and Support from Others 4	Loss of Ability to Take in Caring and Support from Others N/A
High Risk Behaviors	High Risk Behaviors 1	High Risk Behaviors 2	High Risk Behaviors 3	High Risk Behaviors 4	High Risk Behaviors N/A
Traumatic Bonding	Traumatic Bonding 1	Traumatic Bonding 2	Traumatic Bonding 3	Traumatic Bonding 4	Traumatic Bonding N/A
Cycles of Reenactment/Repetition Compulsion	Cycles of Reenactment/Repetition Compulsion 1	Cycles of Reenactment/Repetition Compulsion 2	Cycles of Reenactment/Repetition Compulsion 3	Cycles of Reenactment/Repetition Compulsion 4	Cycles of Reenactment/Repetition Compulsion N/A
Development of Rigid Psychological Defenses	Development of Rigid Psychological Defenses 1	Development of Rigid Psychological Defenses 2	Development of Rigid Psychological Defenses 3	Development of Rigid Psychological Defenses 4	Development of Rigid Psychological Defenses N/A

Other (please specify)

2. How much of each of these qualities do you feel you possess?

Please rate your experience on a scale from 1 (none) to 4 (always)

	1.	2.	3.	4.	N/A
Creativity	*2. How much of each of these qualities do you feel you possess? Please rate your experience on a scale from 1 (none) to 4 (always) Creativity 1.	Creativity 2.	Creativity 3.	Creativity 4.	Creativity N/A
Spirituality	Spirituality 1.	Spirituality 2.	Spirituality 3.	Spirituality 4.	Spirituality N/A
Ability to Reach Out	Ability to Reach Out 1.	Ability to Reach Out 2.	Ability to Reach Out 3.	Ability to Reach Out 4.	Ability to Reach Out N/A
Sensitivity	Sensitivity 1.	Sensitivity 2.	Sensitivity 3.	Sensitivity 4.	Sensitivity N/A
Humility	Humility 1.	Humility 2.	Humility 3.	Humility 4.	Humility N/A
Courage	Courage 1.	Courage 2.	Courage 3.	Courage 4.	Courage N/A
Inventiveness	Inventiveness 1.	Inventiveness 2.	Inventiveness 3.	Inventiveness 4.	Inventiveness N/A
Problem solving skills	Problem solving skills 1.	Problem solving skills 2.	Problem solving skills 3.	Problem solving skills 4.	Problem solving skills N/A
Humor	Humor 1.	Humor 2.	Humor 3.	Humor 4.	Humor N/A
Stick-to-itiveness	Stick-to-itiveness 1.	Stick-to-itiveness 2.	Stick-to-itiveness 3.	Stick-to-itiveness 4.	Stick-to-itiveness N/A
Inner Strength	Inner Strength 1.	Inner Strength 2.	Inner Strength 3.	Inner Strength 4.	Inner Strength N/A
People Skills	People Skills 1.	People Skills 2.	People Skills 3.	People Skills 4.	People Skills N/A
Self Reliance	Self Reliance 1.	Self Reliance 2.	Self Reliance 3.	Self Reliance 4.	Self Reliance N/A
Can Do Attitude	Can Do Attitude 1.	Can Do Attitude 2.	Can Do Attitude 3.	Can Do Attitude 4.	Can Do Attitude N/A
Optimism	Optimism 1.	Optimism 2.	Optimism 3.	Optimism 4.	Optimism N/A
A sense of mastery	A sense of mastery 1.	A sense of mastery 2.	A sense of mastery 3.	A sense of mastery 4.	A sense of mastery N/A
Willingness to change	Willingness to change 1.	Willingness to change 2.	Willingness to change 3.	Willingness to change 4.	Willingness to change N/A
Willingness to fail and try again	Willingness to fail and try again 1.	Willingness to fail and try again 2.	Willingness to fail and try again 3.	Willingness to fail and try again 4.	Willingness to fail and try again N/A
Bonded relationships	Bonded relationships 1.	Bonded relationships 2.	Bonded relationships 3.	Bonded relationships 4.	Bonded relationships N/A
Dedication to healthy self care	Dedication to healthy self care 1.	Dedication to healthy self care 2.	Dedication to healthy self care 3.	Dedication to healthy self care 4.	Dedication to healthy self care N/A
An attitude that life will work out	An attitude that life will work out 1.	An attitude that life will work out 2.	An attitude that life will work out 3.	An attitude that life will work out 4.	An attitude that life will work out N/A
Life Balance	Life Balance 1.	Life Balance 2.	Life Balance 3.	Life Balance 4.	Life Balance N/A
Clear thinking	Clear thinking 1.	Clear thinking 2.	Clear thinking 3.	Clear thinking 4.	Clear thinking N/A
Knowing how to feel good and have fun	Knowing how to feel good and have fun 1.	Knowing how to feel good and have fun 2.	Knowing how to feel good and have fun 3.	Knowing how to feel good and have fun 4.	Knowing how to feel good and have fun N/A
A desire not to self medicate	A desire not to self medicate 1.	A desire not to self medicate 2.	A desire not to self medicate 3.	A desire not to self medicate 4.	A desire not to self medicate N/A

Other (please specify)

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Tian Dayton Trauma SurveyExit this survey

2. How much of each of these qualities do you feel you possess?Please rate your experience on a scale from 1 (none) to 4 (always)

Tian Dayton Trauma Survey
Exit this survey

2. How much of each of these qualities do you feel you possess?

Please rate your experience on a scale from 1 (none) to 4 (always)