PTSD and trauma evaluation report template
A sanitized PTSD and trauma evaluation skeleton in Word format, with adult and child paths in one document. It carries the structure a careful reviewer and an opposing examiner both look for: exposure documented separately from symptoms, the DSM-5-TR criteria walked one at a time against your data, and symptom validity addressed before any score is interpreted. It reads for a clinical evaluation and for an independent examination where a trauma claim is at issue.
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Built for the scrutiny a trauma report actually faces
Trauma reports get questioned on two things above all: whether the diagnosis is mapped to criteria rather than asserted, and whether the self-reported symptoms were tested for validity before they were believed. PTSD is diagnosed largely from self-report, the symptoms are widely known, and in disability and litigation contexts there is potential for secondary gain in either direction. The template is built around both pressures. It documents the qualifying exposure separately from the later symptoms, and it puts a response style, symptom validity, and performance validity section ahead of interpretation.
The history sections prompt for exactly what a formulation and a causation question require: the pre-event baseline, prior traumatic exposures, head injury or loss of consciousness at the event, pain, sleep, and substance use, and the intervening factors that bear on cause. The instruments section is score-and-informant aware but instrument-agnostic, so it works with whatever trauma-specific interviews, self-report inventories, and broadband measures your practice is normed on.
The diagnostic core walks DSM-5-TR Criteria A through H individually, with the required symptom counts noted as you go, and it flags the dissociative subtype and delayed expression specifiers. A separate child and adolescent path maps to the preschool criteria set for children six and younger rather than forcing adult criteria onto a young child. A functional impact section carries the impairment picture, and, where the referral asked, the causation opinion and the standard applied. A basis-and-limitations section and attestation close the report, with the diagnosis left where it belongs: with the clinician.
Every heading, table, and guidance note is editable. Placeholders are bracketed, and italic guidance notes explain what belongs in each section before you delete them. The adult and child paths live in the same file; delete the one you are not using.
About this template
Does it cover adults, children, or both?
Both, in one document. The adult path uses the standard DSM-5-TR PTSD criteria with developmentally appropriate prompts. The child path maps to the separate PTSD for Children 6 Years and Younger criteria set, which has a lower symptom threshold and developmentally expressed symptoms. Delete the path you are not using.
Can I use it for an IME or forensic-adjacent exam?
Yes. It is written to serve both a clinical evaluation and an independent examination where a trauma claim is at issue. It adds fields for the retaining party, the index event date, and the referral question as posed, keeps the pre-event baseline explicit, and gives causation its own section with a prompt for the standard applied and the limits of the opinion. It does not tell you what to conclude.
Why does symptom validity come before interpretation?
Because PTSD is diagnosed largely from self-report, the symptoms are widely known, and there is potential for over-report or under-report in evaluation contexts. Stating the effort and validity findings first, then interpreting the clinical data in that light, is both good practice and the cleanest defense if the report is challenged. The template prompts you to describe the validity pattern rather than to reduce it to a single index.
Is it tied to a particular instrument?
No. The instruments section is score-and-informant aware but instrument-agnostic, so it works with whatever trauma-specific structured interview, self-report inventory, life-events checklist, and broadband measure your practice is normed on. You add one row per measure and informant.
Where does the template come from?
It is the sanitized skeleton of the PTSD and trauma evaluation template that ships inside Boreas Workflow, where it is populated from the case file: intake data, measure scores, interview records, and the clinician's signed diagnostic decisions.
Can I use it without Boreas?
Yes. It is a standard Word document with no macros and no lock-in. If you later want the version that fills itself from an audit-logged case file, that is what the software does.
What do you do with my email?
We send the template, and occasionally new templates and clinical practice content. No list sales, no spam, unsubscribe any time.
The template is the skeleton. Boreas writes the first draft.
Boreas Workflow is a local-first desktop IDE for psychological assessment. Case data never leaves your machine, every diagnostic decision is rendered and signed by you before the writing assistant drafts a line, and measure scores and history flow into the report structure automatically. Reports come out in your voice, structured like this template, so you clear the backlog without cutting the documentation reviewers and opposing examiners expect.