1. Do you have a sense of shame or guilt due to possible sexual abuse?
A. Yes
B. No
C. Not sure
2. Has someone ever touched you in an inappropriate manner?
A. Yes
B. No
C. Not sure
3. Have you developed an addiction or bad behavior to cope with this trauma?
A. Yes
B. No
C. I don't think so
4. Have you experienced unexplainable mental breakdowns?
A. Yes
B. No
C. Sometimes
5. Do you get uncomfortable around certain family members or friends, but you’re not sure why?
A. Yes
B. No
C. Not sure
6. Do you have trouble showing affection towards others?
A. Yes
B. No
C. Sometimes
7. Have you ever been asked to perform a sexual act against your will?
A. Yes
B. No
C. Sometimes
8. Do you have nightmares or trouble sleeping due to this trauma?
A. Yes
B. No
C. Sometimes
9. Has anyone ever forced you to watch pornographic material?
A. Yes
B. No
C. Not sure
10. Have you ever been in a situation in which someone told you to keep what they’ve done to you a secret?
A. Yes
B. No
C. Maybe
