Peace on Wheels Intake

Mobile Mental Health RV Program

Evaluation & Trauma Assessment Tool

This evaluation instrument is designed for mobile community violence response units providing mental health support, outreach, and trauma-informed services to individuals and communities impacted by gun violence.

Important Note: This screening tool is not intended to diagnose PTSD or other mental health conditions. It is designed to help community outreach teams identify trauma exposure, trauma symptoms, and service needs so individuals can be connected with trauma-informed support.

SECTION 1: Participant Information

Date

Staff Member Email

Full Name

Birthdate

Neighborhood / Site

Mobile Unit Location

SECTION 2: ACE-Style Community Violence Exposure Index

Please indicate whether the participant has experienced the following events at ANY point in their life.

	Yes	No
1. Witnessed someone being shot
2. Been shot or physically injured by a firearm
3. Lost a family member to gun violence
4. Lost a close friend to gun violence
5. Witnessed someone seriously injured due to gun violence
6. Heard gunshots frequently in your neighborhood
7. Been threatened with a gun
8. Been physically assaulted during a violent incident
9. Seen a dead body in the community due to violence
10. Had a family member incarcerated due to violence
11. Had a close friend incarcerated due to violence
12. Grew up in a household where violence was common
13. Experienced repeated bullying or physical threats
14. Had to move homes because of neighborhood violence

Total Violence Exposure Score (max 14)

Attitudes Toward Violence & Conflict Resolution

1 = Strongly disagree
2 = Disagree
3 = Neutral
4 = Agree
5 = Strongly agree

	1	2	3	4	5
It is okay to hit someone if they deserve it.
Carrying a gun makes a person safer.
Sometimes you need to threaten others to get what you want.
My friends believe that fighting is an acceptable way to solve problems.
I am able to calm myself down when I get angry.
When someone disrespects me, I try to resolve the issue peacefully.

Total Attitude & Conflict Score (max 30)

When faced with a conflict, how do you usually respond?

Other (please specify):

SECTION 3: Neighborhood Safety Perception Scale

Please indicate how much you agree with the following statements.

1 = Strongly disagree
2 = Disagree
3 = Neutral
4 = Agree
5 = Strongly agree

	1	2	3	4	5
1. I feel safe walking in my neighborhood during the day.
2. I feel safe walking in my neighborhood at night.
3. I worry about being harmed by violence in my neighborhood.
4. I avoid certain streets or areas because of safety concerns.
5. I believe shootings or violent incidents could happen near me.
6. People in my neighborhood look out for one another.
7. I would feel comfortable asking neighbors for help in an emergency.
8. I believe community programs are helping improve neighborhood safety.
9. Adults in my community encourage young people to avoid violence.
10. I have at least one adult mentor or community leader I can talk to about personal issues.

Safety Perception Score (max 50)

My friends carry guns.

YesNo

Have you ever carried a gun for protection?

YesNo

SECTION 4: Trauma Symptom Screening (PCL-5 Aligned)

In the past 30 days, how much have you been bothered by the following problems related to a stressful or violent experience?

0 = Not at all
1 = A little bit bothered
2 = Moderately bothered
3 = Quite a bit bothered
4 = Extremely bothered

	0	1	2	3	4
1. Repeated disturbing memories of a violent event
2. Repeated disturbing dreams about violence
3. Suddenly feeling or acting as if the event were happening again
4. Feeling very upset when reminded of a violent event
5. Strong physical reactions when reminded of violence
6. Avoiding memories, thoughts, or feelings related to violence
7. Avoiding people, places, or situations that remind you of violence
8. Trouble remembering important parts of the violent event
9. Negative beliefs about yourself, others, or the world due to violence
10. Blaming yourself or someone else for the violent event
11. Strong negative emotions such as fear, anger, guilt, or shame
12. Loss of interest in activities you once enjoyed
13. Feeling distant or cut off from other people
14. Difficulty experiencing positive emotions
15. Irritable behavior or angry outbursts
16. Taking risks or engaging in reckless behavior
17. Being overly alert or watchful (hypervigilance)
18. Being easily startled
19. Difficulty concentrating
20. Trouble falling or staying asleep

Total Trauma Score (max 80)

SECTION 5: Service Impact

These questions help evaluate the impact of the mobile mental health unit.

Are you interested in follow-up support or services?

YesNo

Did the mobile unit make it easier for you to access mental health support?

YesNo

Before today, had you ever spoken to a mental health professional about trauma or violence?

YesNo

SECTION 6: Staff Observation Notes

Observations to be completed by the staff member conducting the assessment.

Observed emotional state

Immediate safety concerns

Referrals made

Follow-up needed