Root Cause Assessment "*" indicates required fields Past experiences haunt almost all of us. The THG Root Cause & Symptom Assessment will help your therapist understand the ways your past may still be impacting your present, and more importantly, what therapeutic techniques can be used to reduce any dysfunctional coping mechanisms. Read each of the following statements and check those that you feel apply to you. Although the statements are written in the present tense, place a check next to the item if it has applied to you anytime in the past 12 months. Statements should only be considered false if they have never been a part of your life or haven't been part of your life for at least 1 year. When in doubt, let your first reaction be your guide. Please enter your name and birthdate for our reference:Full Legal Name* First Last Birthdate* MM slash DD slash YYYY Counselor* First Last Statements1 I sometimes feel like a past painful experience is still happening now. 2 It is difficult for me to stop a childhood pattern that is harmful to myself 3 I think a lot about people who have hurt me in the past. 4 I have chronic sore throats and/or neck pain. 5 I enjoy taking risks. 6 I sometimes have difficulty staying awake. 7 I feel like I have had an “out of body experience” as a reaction to a flashback or memory. 8 I avoid sexual pleasure. 9 I have bad dreams about past experiences. 10 I repeat painful experiences over and over. 11 Anniversary dates are very significant for me even when associated with an unhealthy person. 12 I have secrets that I have never told anyone. 13 I sometimes engage in high risk behaviors. 14 I eat excessively to avoid feeling bad. 15 I avoid thoughts or feelings associated with bad experiences from my past. 16 I skip vacations because of lack of time or money. 17 There are periods when I have a hard time falling asleep. 18 I try to recreate a past traumatic experience. 19 I keep secrets for people who have hurt me. 20 I try hard to be perfect. 21 I feel sexual when I am frightened. 22 I drink to excess when life gets too hard. 23 I avoid books, songs, or movies that remind me of painful experiences. 24 I sometimes deny myself basic needs like groceries, clothes, or medical care. 25 Painful experiences sometimes play over and over in my head. 26 There is something destructive in my life that I keep repeating. 27 I have stayed in conflict with someone when I should have walked away. 28 I have suicidal thoughts or feelings of “I wish I were dead”. 29 I often feel sexual when I am lonely. 30 I use drugs or alcohol as a way to help deal with my life. 31 I am unable to recall important details of past painful experiences. 32 I avoid doing normal activities (showering, shopping, bill paying, etc.) out of fear. 33 I have sudden or vivid flashbacks of painful experiences. 34 I try to stop activities that I know are not helpful, but without success. 35 I go “overboard” to help people who have been harmful to me. 36 I often feel distant from others because of painful experiences I have had. 37 I feel intensely sexual when violence occurs. 38 I procrastinate to the point that it causes problems in my life (work, bills not getting paid, etc.) 39 I sometimes withdraw or have a lack of interest in important activities (friends, family, career, etc.) 40 I will hoard money and not spend it on legitimate needs. 41 I feel upset when there are reminders of past bad experiences (ex. Dates, places, songs, etc.) 42 I compulsively do things to others that were done to me as a child. 43 I sometimes help people who have been (or still are) exploitive or manipulative to me. 44 I feel unable to experience certain emotions (love, happiness, sadness, etc.) 45 I feel sexual when degraded or used. 46 I sometimes sleep too much in order to avoid dealing with life’s problems. 47 I often have difficulty concentrating. 48 I am often dieting. 49 There are periods when I have a hard time staying asleep. 50 My relationships seem to be the same story over and over again, just with different people. 51 I have chronic neck and/or shoulder pain. 52 I have a dim outlook on my future. 53 I would feel excited by walking alone at night in a “bad section of town”. 54 I can become preoccupied with food and eating. 55 I often experience confusion. 56 I refuse to buy things even when I need them and have the money. 57 I often don’t feel sexual. 58 I find myself repeating a destructive childhood event. 59 I remain a “team player” even though it is obvious that it will not benefit me. 60 I often feel like I am on the outside of relationships (never part of the inner circle). 61 I sometimes feel bad because I enjoyed experiences that were exploitive of me. 62 I abuse alcohol or other drugs often. 63 I can’t remember significant periods of time from my childhood. 64 I have chronic low-back pain. 65 I have outbursts of anger or am often irritable. 66 I do things to others that were done to me in my family. 67 I make repeated efforts to win over people who are destructive to me. 68 I engage in self-destructive behaviors. 69 I get a high on activities that are dangerous to me. 70 I use TV, video games, or other hobbies as a way to numb out. 71 I go into a fantasy world when things are hard. 72 I am underemployed. 73 I am extremely cautious of my surroundings. 74 I have repetitive thoughts and behaviors that do not feel good to me. 75 I attempt to be liked by people who clearly were exploiting me. 76 I get excited/aroused when faced with dangerous situations. 77 I use drugs like cocaine or amphetamines to help me feel alive. 78 I exercise excessively to avoid feeling negative emotions. 79 I use romance as a way to avoid problems. 80 I feel very guilty about sexual activity. 81 I often feel that people want to take advantage of me. 82 I revert to doing things I did as a child. 83 I am attracted to untrustworthy people. 84 I put up with physical or emotional pain that most people would not tolerate. 85 I like living on the edge of danger or excitement. 86 When things are difficult, I will sometimes binge eat. 87 I have a tendency to be preoccupied with something other than what I need to be focused on. 88 I experience periods of having no interest in eating. 89 I have chronic stomach aches/pain or digestive issues. 90 Some of my recurring behaviors come from early life experiences. 91 I trust people who are proven unreliable. 92 I have attempted suicide. 93 People might consider me an adrenaline junkie. 94 I use alcohol and/or drugs to escape. 95 I use marijuana or psychedelics to hallucinate. 96 I sometimes self-sabotage opportunities for success. 97 I get startled more easily than other people I know. 98 I am preoccupied with children of a certain age. 99 I seek out people who I know will cause me pain. 100 I avoid mistakes at any cost. 101 I love to gamble on outcomes. 102 I could be considered a workaholic. 103 I will often lose myself in fantasies rather than deal with real life. 104 I go without certain necessities for periods of time. 105 I get physical reactions to reminders of my past (cold sweat, trouble breathing, knot in throat, etc.) 106 I engage in abusive relationships repeatedly. 107 I have difficulty retreating from unhealthy relationships. 108 I sometimes feel bad about myself because of shameful experiences I believe were my fault. 109 I need lots of stimulation to avoid feeling bored. 110 I can get so lost in something that I forget to eat. 111 I live a double life. 112 I sometimes vomit food or use diuretics to avoid weight gain. 113 I feel anxious when I think about being sexual. 114 My life seems to be a repetition of the same bad circumstances over and over again. 115 I try hard to be understood by people who really don’t care about me. 116 I often feel unworthy, unlovable, immoral, or sinful because of experiences I have had. 117 I feel excited when hurt or beaten. 118 I find it hard to just sit in uncomfortable feelings. 119 I have a life of compartments that others do not know about. 120 Feelings of guilt often keep me from enjoying the pleasures of life. 121 I find it difficult to trust people. 122 There are activities that I have trouble stopping even though they are useless or destructive. 123 I am in emotional fights (divorces, lawsuits, etc.) that seem like they will never end. 124 I often feel I should be punished for my past actions. 125 I engage in high-risk sexual activity. 126 If I start to feel anxious, I will do something (or anything) to avoid that feeling. 127 I have a fantasy life that I retreat into when things are difficult. 128 I find it difficult to just play or relax. 129 I wake up to bad dreams. 130 My relationships seem to have the same dysfunctional pattern. 131 There are certain people who I always allow to take advantage of me. 132 I feel that others are always better off than me. 133 I use cocaine or amphetamines to heighten “high risk” activities. 134 I don’t tolerate uncomfortable feelings. 135 I am a frequent daydreamer. 136 At times, I view things like vacations, entertainment, or play activities as frivolous. 137 I hate it when someone seems sexually attracted to me. 138 Sometimes I find children more attractive than adults. 139 There are some people in my life who are hard to get over even though they hurt or used me badly. 140 I have done self-mutilating behaviors (intentional cutting, burning, etc.) 141 I get excited or aroused when I am in dangerous situations. 142 I will often find anything to distract me from my problems. 143 Sometimes I live in an unreal world. 144 Sometimes I feel like I don’t deserve to have fun or be happy. HiddenTreatment ResponseHiddenPRPhysical ReactionsHiddenTRTrauma RepetitionHiddenTBTrauma BondsHiddenSHShameHiddenRSKRisky BehaviorHiddenBLKBlockingHiddenDSDissociationHiddenABAbstinenceHiddenEDEating DisorderHiddenSASubstance AbuseHiddenPPPhysical PainHiddenDEDepression HiddenAXAnxiety HiddenSDSleep DisorderHiddenSXSex AddictionHiddenGFGriefEmailThis field is for validation purposes and should be left unchanged.
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