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A trauma assessment is a structured clinical evaluation of a client's trauma history, current trauma- and stressor-related symptoms, dissociation, and immediate safety. Psychologists, therapists, and counselors complete one at intake, or when trauma surfaces during treatment, usually pairing a clinical interview with a validated screen such as the PCL-5 or PC-PTSD-5. A typical trauma assessment runs 300 to 900 words.
Psychologists, therapists, counselors, clinical social workers
Treating clinician, downstream treatment team, supervisors, payers
300 to 900 words · 20 to 40 minutes by hand (clinical team estimate)
Structured intake assessment (compare: intake note, biopsychosocial assessment)
At intake, or when trauma history emerges during treatment
A clinical convention, not a mandated form: no US, Canadian, or Australian law requires a specific trauma assessment; content follows HIPAA and payer rules
A trauma assessment is a structured clinical evaluation of a client's history of traumatic events and their current trauma- and stressor-related symptoms, dissociation, and immediate safety. It goes deeper than the trauma question on a general intake, and clinicians also call it a trauma history interview, a trauma screening, or simply the trauma part of the formulation. In DSM-5-TR it maps to the trauma- and stressor-related disorders (PTSD, acute stress disorder, and the adjustment disorders); ICD-11 adds a separate complex PTSD diagnosis for prolonged or repeated interpersonal trauma, which the DSM does not name.
Two distinctions keep the assessment honest. First, exposure is not a diagnosis. DSM-5-TR Criterion A defines a traumatic event narrowly, as exposure to actual or threatened death, serious injury, or sexual violence, and many people with real, painful histories do not meet the full criteria for PTSD. The assessment documents what happened and what the symptoms are, then lets the diagnosis follow. Second, no law requires a particular trauma form or a specific questionnaire. SAMHSA's trauma-informed care model is a framework, not a mandate, and screening tools like the PCL-5 or the ACE questionnaire are professional convention rather than a statutory requirement. What payers and boards expect is that the record be accurate, complete, and tied to the care you provide.
Trauma assessments are used across outpatient mental health, community behavioral health, integrated primary care, trauma-specialty and veterans' clinics, substance use programs (where trauma and substance use often co-occur), and child and adolescent services. A clinician reaches for a dedicated trauma assessment when trauma is the presenting concern, when a screen flags it, or when trauma history emerges mid-treatment and the brief trauma section inside a general case formulation or intake is no longer enough. It goes deeper than that section: a structured event screen, symptoms mapped to the trauma diagnoses, dissociation, and current safety, so the resulting treatment plan is built on the full picture.
There is no single mandated trauma assessment form. The sections below are the ones auditors, supervisors, and the next clinician expect to see, each with the pitfall that most often undermines it.
Referral and presenting concern. Why the assessment is happening now, the referral question, and the client's own words about what brings them in. Pitfall: moving into event details before establishing why the assessment is happening and what the client wants from it.
Trauma history. A structured screen of potentially traumatic events across the lifespan (a tool such as the LEC-5 helps), then the index event or events in the client's words, with only the detail that is clinically necessary. Pitfall: pressing for a vivid narrative of every event; over-detailed disclosure at a first meeting can retraumatize and is rarely needed to reach a diagnosis or a plan.
Current symptoms. Trauma- and stressor-related symptoms mapped to the four PTSD clusters (intrusion; avoidance; negative alterations in cognition and mood; arousal and reactivity), ideally anchored to a validated measure such as the PCL-5. Pitfall: recording a total score with no symptom detail, or symptom detail with no measure; the record wants both.
Dissociation. Screen for depersonalization, derealization, and gaps in memory, since they change treatment pacing and can flag the dissociative subtype of PTSD. Pitfall: skipping dissociation altogether; it is one of the most under-documented sections and it directly shapes the plan.
Safety and current risk. Current safety, suicidal and self-harm risk, and any ongoing threat such as active abuse or intimate-partner violence. Pitfall: documenting the trauma as historical while missing that the client is still in an unsafe situation now.
Strengths, supports, and coping. Protective factors, social support, cultural and spiritual resources, and the coping strategies the client already uses. Pitfall: a deficit-only assessment; without strengths the record cannot support a realistic, trauma-informed plan.
Functional impact. How symptoms affect work, relationships, parenting, sleep, and daily functioning. Pitfall: listing symptoms without tying them to impairment, which is what supports medical necessity.
Clinical formulation and diagnostic impression. Your integrated understanding: whether criteria for PTSD, acute stress disorder, an adjustment disorder, or another condition are met, and the mechanisms that link history to presentation. Pitfall: treating “has a trauma history” as “has PTSD”; many trauma-exposed clients do not meet the criteria.
Recommendations and plan. Trauma-informed next steps: modality, pacing, referrals, safety planning where indicated, and follow-up. Pitfall: recommending trauma-focused processing before the client has the stabilization and safety to tolerate it.
Client: [initials] Date: Clinician: Referral / presenting concern: Trauma history (event screen, index event, age / onset): Current symptoms: Intrusion: Avoidance: Negative cognition / mood: Arousal / reactivity: Measure + score (e.g., PCL-5): Dissociation (depersonalization / derealization / memory gaps): Safety & current risk (safety now, SI / self-harm, ongoing threat): Strengths, supports & coping: Functional impact (work / relationships / sleep / daily life): Clinical formulation & diagnostic impression: Recommendations & plan (modality, pacing, referrals, follow-up): Clinician signature / credentials: Date signed:
Free to use and share, no signup. The PDF includes a one-page cheat sheet with section-by-section pitfalls and a pre-sign checklist; the DOCX is the blank template, ready to adapt.
Scenario: adult client, single-incident trauma (a highway collision) four months ago, referred by primary care. All details are fictional.
Client: R.O., 41 · Date: 07/09/2026 · Type: Trauma assessment (intake) · Referral: primary care
Referral and presenting concern: Referred by primary care after four months of nightmares and feeling “on edge” since a highway collision. Wants to sleep through the night and drive on highways again.
Trauma history: Life Events Checklist completed. Index event: a multi-vehicle highway collision (04/2026); client was the driver, treated in the emergency department and released the same day. No other events endorsed at a Criterion A level. No reported childhood abuse; a brief ACE screen was positive for one item (parental divorce).
Current symptoms: Intrusion: near-nightly nightmares, intrusive images when merging into traffic. Avoidance: has not driven on highways since the collision; avoids news coverage of crashes. Negative cognition and mood: persistent belief that “the roads are not safe,” loss of interest in weekend cycling. Arousal: hypervigilance in traffic, exaggerated startle, initial insomnia. PCL-5 today: 42.
Dissociation: Reports briefly “spacing out” at the moment of impact; denies current depersonalization, derealization, or memory gaps. Does not meet the threshold for the dissociative subtype.
Safety and current risk: Denies suicidal ideation, self-harm, and homicidal ideation. No ongoing threat or unsafe situation. Drives local roads cautiously without impairment. Routine monitoring; no safety plan indicated at this time.
Strengths, supports, and coping: Stable marriage and employment, supportive spouse, uses paced breathing, motivated and psychologically minded.
Functional impact: Sleep reduced to about five hours nightly; declined a promotion that required a highway commute; increased irritability at home. Work performance otherwise maintained.
Clinical formulation and diagnostic impression: Symptoms span all four clusters, have persisted more than one month, and cause functional impairment; the presentation is consistent with post-traumatic stress disorder following a single-incident adult trauma. No dissociative subtype. Short duration and strong protective factors suggest a good prognosis. Provisional: post-traumatic stress disorder.
Recommendations and plan: Begin a trauma-focused therapy (for example prolonged exposure or cognitive processing therapy) after two stabilization sessions; add sleep and nightmare-focused strategies; re-administer the PCL-5 at session 4 and monthly; coordinate with the primary care physician. Next appointment 07/16/2026.
This sample is fictional and for educational purposes. It does not describe a real patient.
Writing these after every session? BastionGPT drafts complete notes from bullets, dictation, or a transcript.
Generate a note from bulletsA trauma assessment is part of the designated record set: the client can request it, payers can audit it, and the next clinician relies on it. Write it so all three can read it, and keep the level of trauma detail proportionate to what the diagnosis and plan actually require, rather than a verbatim narrative of every event. Auditors and payers expect the assessment to be thorough, dated, and signed, with a documented Criterion A event where PTSD is diagnosed, a mental status exam, an explicit risk assessment, and diagnoses supported by the findings. When a pre-licensed clinician conducts it, most boards expect a licensed supervisor to co-sign. Retention is set by state and payer rules, not by HIPAA, which does not dictate how long patient charts are kept; a common floor is at least seven years for adults and until the age of majority plus several years for minors, and Medicaid work often carries a longer window because the federal False Claims Act allows audits up to ten years back.
On the payer side, the trauma assessment usually lives inside the diagnostic evaluation billed as 90791, or 90792 when a medical component is furnished, so the content, not the format, carries medical necessity: Medicare contractor guidance expects the record to support the diagnosis and the service billed. The trauma-informed framing is guidance, not a mandated form, and no regulation requires a specific questionnaire such as the ACE or the LEC-5; those are convention. Two content points do carry real weight. If the assessment is done inside a substance use treatment program, its contents are protected by 42 CFR Part 2, a stricter federal standard than HIPAA that needs specific consent to disclose. And because trauma and acute risk often travel together, current safety and suicide or self-harm risk belong on every assessment, even when the finding is negative. If you or a client needs immediate support: call or text 988 (US), 9-8-8 (Canada), or Lifeline 13 11 14 (Australia).
The failures that get trauma assessments denied are documentation failures, not format choices. Payers deny the diagnostic evaluations these assessments support for insufficient documentation of medical necessity: an omitted mental status exam, a missing or unsigned risk assessment, or a diagnosis the record does not support. There is no claim-denial code specific to a “missing trauma assessment”; the denials read generically, as diagnosis not supported by the medical record, or documentation does not meet payer policy. The backdrop is a high-prevalence one, which is part of why the record matters: CDC data show 63.9% of US adults report at least one adverse childhood experience and 17.3% report four or more, and about 5% of US adults have PTSD in a given year. The BastionGPT Clinical Advisory Board sees the same errors most often in trauma assessment reviews:
BastionGPT is specifically trained, tuned, and clinically tested on trauma assessments.
See how clinicians use it day to day on the AI therapy notes page.
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HIPAA-compliant with a signed BAA on every plan. Your data is never used to train models. BastionGPT drafts, you review and sign.
As detailed as it takes to justify the diagnosis and the plan: which events meet DSM-5-TR Criterion A, roughly when they happened, and how the symptoms connect. Pair a screening score such as the PCL-5 or PC-PTSD-5 with a short narrative in the client's words. More graphic detail than the diagnosis and plan require adds privacy risk without adding clinical value. See the case formulation for how the history feeds your working hypothesis.
No. No US, Canadian, or Australian law mandates a particular trauma form, and no payer requires a specific questionnaire like the ACE or the LEC-5. What Medicare and other payers require is that the diagnostic evaluation be medically necessary and that the record support the diagnosis and the service billed. SAMHSA's trauma-informed care is a framework, not a mandated form.
An intake note is a brief first-session record; a biopsychosocial, often billed as the 90791 diagnostic evaluation, is the broad, multi-domain assessment. A trauma assessment goes deep on one domain: the trauma history, symptoms, dissociation, and safety, and it usually lives inside that larger evaluation. Its output feeds the treatment plan.
No. Exposure is not a diagnosis. DSM-5-TR Criterion A is specific, and many people with real trauma histories meet criteria for an adjustment disorder, for ICD-11 complex PTSD, or for no trauma disorder at all. The assessment documents the history and the symptoms; the diagnosis follows from the criteria and the duration.
The most common come from the VA's National Center for PTSD: the PCL-5 (a 20-item self-report), the PC-PTSD-5 (a 5-item primary-care screen), the LEC-5 (a life-events exposure checklist), and the clinician-administered CAPS-5. The ACE questionnaire covers childhood adversity. A PCL-5 score around 31 to 33 is widely used as a provisional PTSD cutoff, though no single cutpoint fits every setting or population.
Only if it fits your setting or population. ACE screening is not required by law anywhere. Some programs incentivize it (California's Medi-Cal ACEs Aware initiative pays trained providers) but do not mandate it, and beneficiaries cannot be forced to screen. If you use an ACE tool, document how you will act on a high score.
There is no universal HIPAA rule for patient charts; retention comes from state and payer rules. A common floor is at least seven years for adults and until the age of majority plus several years for minors, with longer windows where Medicaid or litigation exposure applies. Check your jurisdiction and payer contracts.
Yes. Give it your interview notes, a screening tool's results, or a dictation, and it drafts a structured assessment for your review, keeping the trauma history in the client's frame. It can also check a draft for gaps such as a missing dissociation or safety section. BastionGPT is HIPAA-compliant with a signed BAA on every plan, and your data is never used to train models.
The compliance and clinical claims on this page trace to these authorities, last verified July 2026:
Educational content, not legal or billing advice. Sample notes are fictional. Follow your organization's policies and your board, payer, and jurisdiction requirements.