About this template
The PCL-C (PTSD Checklist - Civilian Version) is a widely utilized self-assessment tool designed to help individuals evaluate their responses to stressful life experiences. This form guides respondents through a standardized series of questions regarding symptoms experienced over the past month, such as intrusive thoughts, avoidance behaviors, emotional numbness, and hyperarousal.
Healthcare providers, therapists, and counseling centers use this questionnaire for clinical intakes, ongoing therapeutic progress tracking, and psychological evaluations. By converting this assessment into an online format, practitioners can securely collect pre-appointment data, allowing clients to complete the questionnaire at their own pace before a session.
Doc2Form makes it effortless to deploy this clinical assessment as a professional Google Form, ensuring responses flow directly into your secure Google Workspace for easy review and record-keeping.
Key features
- Standardized 17-item civilian PTSD symptom checklist
- Collects pre-session intakes directly into Google Drive
- Clear rating scales for symptom severity and frequency
- Easy to customize with your clinic or practice branding
- Accessible on mobile, tablet, and desktop devices
Use cases
- Initial clinical intakes at mental health and counseling clinics
- Ongoing therapeutic progress monitoring and symptom tracking
- Telehealth remote patient screening before virtual appointments
- Research studies on civilian trauma and stress responses
What this form collects
- Unique Identifier (Short answer)Enter your client ID, initials, or case number.
- Date (Date)Select today's date.
- Repeated, disturbing memories, thoughts, or images of a stressful experience? (Multiple choice)Indicate how much you have been bothered by this in the past month.
- Repeated, disturbing dreams of a stressful experience? (Multiple choice)Indicate how much you have been bothered by this in the past month.
- Suddenly acting or feeling as if a stressful experience were happening again? (Multiple choice)Indicate how much you have been bothered by this in the past month.
- Feeling very upset when something reminded you of a stressful experience? (Multiple choice)Indicate how much you have been bothered by this in the past month.
- Having physical reactions when something reminded you of a stressful experience? (Multiple choice)Examples include heart pounding, trouble breathing, sweating, etc.
- Avoiding thoughts or feelings associated with a stressful experience? (Multiple choice)Indicate how much you have been bothered by this in the past month.
- Avoiding activities or situations because they reminded you of a stressful experience? (Multiple choice)Indicate how much you have been bothered by this in the past month.
- Trouble remembering an important part of a stressful experience? (Multiple choice)Indicate how much you have been bothered by this in the past month.
- Loss of interest in things that you used to enjoy? (Multiple choice)Indicate how much you have been bothered by this in the past month.
- Feeling distant or cut off from other people? (Multiple choice)Indicate how much you have been bothered by this in the past month.
- Feeling emotionally numb or unable to have loving feelings? (Multiple choice)Indicate how much you have been bothered by this in the past month.
- Feeling as if your future will somehow be cut short? (Multiple choice)Indicate how much you have been bothered by this in the past month.
- Trouble falling or staying asleep? (Multiple choice)Indicate how much you have been bothered by this in the past month.
- Feeling irritable or having angry outbursts? (Multiple choice)Indicate how much you have been bothered by this in the past month.
- Having difficulty concentrating? (Multiple choice)Indicate how much you have been bothered by this in the past month.
- Being 'superalert' or watchful on guard? (Multiple choice)Indicate how much you have been bothered by this in the past month.
- Feeling jumpy or easily startled? (Multiple choice)Indicate how much you have been bothered by this in the past month.
- Total Score or Notes (Paragraph)Optional space for calculated scoring or clinician notes.
FAQ
How do I use this PTSD Checklist template?
Simply click to import this template directly into your Google Forms account. Once added, you can customize the questions, adjust sharing settings, and send it to clients.
Is this form suitable for clinical use?
Yes, the questions mirror the standard PCL-C civilian assessment criteria used by mental health professionals to screen for post-traumatic stress symptoms.
Where are patient responses stored?
All submissions go directly to a secure Google Sheet linked to your Google Form, keeping your data within your organization's Google Workspace.
Can I edit the questions on this form?
Yes, because it becomes a standard Google Form in your account, you have full control to add, remove, or modify any questions as needed.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.