Adverse Childhood Experiences Questionaire

Phone

(###)

###

####

Name *

First Name

Last Name

Have you ever been incarcerated

Yes

No

While you were growing up how often did a parent, step-parent, or another adult living in your home swear at you, insult you, or put you down?

More than once

Once

Never

While you were growing up how often did a parent, step-parent, or another adult living in your home act in a way that made you afraid that you would be physically hurt?

More than once

Once

Never

While you were growing up did a parent, step-parent, or another adult living in your home push, grab, shove, or slap you?

More than once

Once

Never

While you were growing up did a parent, step-parent, or another adult living in your home hit you so hard that you had marks or were injured?

More than once

Once

Never

During the first 18 years of life, did an adult or older relative, family friend, or stranger who was at least five years older than yourself ever touch or fondle you in a sexual way or have you touch their body in a sexual way?

Yes

No

Did they attempt to have or actually have any type of sexual intercourse, oral, anal or vaginal with you?

Yes

No

Was there was someone in your life who helped you feel important or special.

Very often true

Often True

Sometimes true

Rarely true

Never

Your family sometimes cut the size of meals or skipped meals because there was not enough money in the budget for food.

Very often true

Often True

Sometimes true

Rarely true

Never true

How often, if ever, did you see or hear in your home a parent, step parent, or another adult who was helping to raise you being slapped, kicked, punched, or beaten up?

Many times

A few times

Once

Never

How often, if ever, did you see or hear in your home a parent, step parent, or another adult who was helping to raise you being hit or cut with an object, such as a stick, cane, bottle, club, knife or gun?

Many times

A few times

Once

Never

Did you live with anyone who was a problem drinker or alcoholic?

Yes

No

Did you live with anyone who used illegal street drugs or who abused prescription medications?

Yes

No

While you were growing up, did you live with anyone who was depressed or mentally ill?

Yes

No

Did you live with anyone who was suicidal?

Yes

No

Were your parents were ever separated or divorced?

Yes

No

Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?

Yes

No

How often, if ever, did you see or hear someone being beaten up, stabbed, or shot in real life?

Yes

No

While you were growing up…How often did you feel that you were treated badly or unfairly because of your race or ethnicity?

Yes

No

Did you feel safe in your neighborhood?

All of the time

Most of the time

Some of the time

None of the time

Did you feel people in your neighborhood looked out for each other, stood up for each other, and could be trusted?

All of the time

Most of the time

Some of the time

None of the time

How often were you bullied by a peer or classmate?

All of the time

Most of the time

Some of the time

None of the time

Were you ever in foster care?

Yes

No