ACES Self Assessment Form

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:

Did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate you?
Did a parent or other adult in the household often act in a way that made you afraid that you might be physically hurt?
Did a parent or other adult in the household often Push, grab, slap, or throw something at you?
Did a parent or other adult in the household ever hit you so hard that you had marks or were injured?
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?
Did an adult or person at least 5 years older than you ever Attempt or actually have oral, anal, or vaginal intercourse with you?
Did you often feel that no one in your family loved you or thought you were important or special?
Did you often feel that your family didn’t look out for each other, feel close to each other, or support each other?
Did you often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?
Did you often feel that your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Were your parents ever separated or divorced?
Were any of your parents or other adult caregivers often pushed, grabbed, slapped, or had something thrown at them?
Were any of your parents or other adult caregivers sometimes or often kicked, bitten, hit with a fist, or hit with something hard?
Were any of your parents or other adult caregivers ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
Was a household member depressed or mentally ill, or did a household member attempt suicide?
Did a household member go to prison?