School Grade
		Fetus	Baby	Toddler		Pre School			1st	2nd	3rd	4th	5th	6th	7th	8th	9th	10th	11th	12th
Age at Time of Trauma		0	1	2	3	4	5		6	7	8	9	10	11	12	13	14	15	16	17
Status of Pregnant Mother, if known
Describe Life Event

Document significant traumas experienced that impacted your life.  Copy this and add as many lines/pages as necessary. Draw a line if it crossed an age range.  Sometimes it takes months to remember significant events.  You may list what is remembered by siblings if you choose to, especially if events impacted your life.   Trigger words are divorce, abuse, beatings, fire, abandonment, broken bones, hospitalization, moving, foster care, to name a few.

This abbreviated form allows for faster downloading.

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