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Adverse Childhood Experience (ACE) Questionnaire

This questionnaire will be asking you some questions about events that happened during your childhood; specifically the first 18 years of your life. The information you provide by answering these questions will allow us to better understand problems that may have occurred early in your life and allow us to explore how those problems may be impacting the challenges you are experiencing today. This can be very helpful in the success of your treatment.

While you were growing up, during your first 18 years of life:

1. Did a parent or other adult in the household often: swear at you, insult you, put you down, or humiliate you? OR Act in a way that made you afraid that you might be physically hurt?
2. Did a parent or other adult in the household often: Push, grab, slap, or throw something at you?
3. Did an adult or person at least 5 years older than you ever: touch or fondle you or have you touch their body in a sexual way?
4. Did you often feel that: no one in your family loved you or thought you were important or special? OR your family didn't look out for each other, feel close to each other, or support each other?
5. Did you often feel that: you didn't have enough to eat, had to wear dirty clothes, and had no one to protect you? OR your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
6. Were your parents every separated or divorced?
7. Were any of your parents or other adult caregivers: often pushed grabbed, slapped, or had something thrown at them? OR sometimes or often kicked, bitten, hit with a fist, or hit with something hard?
8. Did you live with anyone who was a problem drinker or alcoholic, or used street drugs?
9. Was a household member depressed or mentally ill, or did a household member attempt suicide?
10. Did a household member go to prison?

Thanks for submitting!

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