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Secondary Trauma Assessment & Self-Care Plan

Assess the impact of supporting a trauma survivor on YOUR system, and build a sustainable care plan.

Week 11

Appendix K

Secondary Traumatic Stress Assessment

Hypervigilance (always scanning for their mood/state): 0-4

Sleep disruption: 0-4

Emotional numbing: 0-4

Irritability/short fuse: 0-4

Social isolation: 0-4

Loss of identity: 0-4

Intrusive thoughts about their trauma: 0-4

Physical symptoms: 0-4

Hopelessness: 0-4

TOTAL (0-36): Mild 0-9 | Moderate 10-18 | Significant 19-27 | Severe 28-36

My Self-Care Plan (Structural)

Non-negotiable time for myself (when, how often, what):

My support person (who knows what I'm going through):

Physical basics I'm committing to (sleep, movement, food):

My OWN regulation practice:

Something that's MINE (not about caregiving):

My own therapeutic support (current or plan to find):

Example: Example Entry

A sample self-care plan.