ACE Questionnaire | NewLeaf Counseling of the River Valley

ADVERSE CHILDHOOD EXPERIENCE (ACE) QUESTIONNAIRE

Initials

Date of Scheduled Appointment and Time

Directions: Of the following questions, please type in “Yes” or “No” to the best of your recollection. If you answer "Yes" please describe, in as much detail as you are comfortable with, your experience and the persons associated. Please base all of your answers on events that occurred during the first 18 years of your life.

EMOTIONAL ABUSE:

1a. Did a parent or other adult in the household often or very 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?

1b. Did you often or very 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?

NEGLECT:

2. Did you often or very 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?

PHYSICAL ABUSE:

3. Did a parent or other adult in the household often or very often… push, grab, slap, or throw something at you or ever hit you so hard that you had marks or were injured?

SEXUAL ABUSE:

4. 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, or try to or actually have oral, anal, or vaginal sex with you?

FAMILY DYSFUNCTION:

5. Were your parents ever separated or divorced?

6. Was your mother or stepmother often or very often… pushed, grabbed, slapped, or had something thrown at her, or often or very often kicked, bitten, hit with a fist, or hit with something hard?

7. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?

8. Was a household member depressed or mentally ill or did a household member attempt suicide?

9. Did a household member go to prison?

Directions: For this last question, please type in “Yes” or “No” to the best of your recollection. If you answer "Yes" please describe, in as much detail as you are comfortable with, your experiences and the persons associated. Please base your answer for any events that have occurred at any point in your life (as a child, teenager, or adult).

10. Have you ever experienced a traumatizing situation in which you felt like yours, or the life of someone close to you, was threatened? Any kind of experienced or witnessed trauma? How old were you?

By clicking "submit" below, I express understanding that the information I am providing will be utilized by a licensed mental health professional solely for the purposes of better understanding my experience as it currently relates to my symptoms. This information will be utilized, along with further information that will be gathered during my evaluation, in order to formulate a diagnosis. All of the information I have supplied is true to the best of my recollection, and I understand that any false information I provide may lead to misdiagnosis which may hinder services for myself. I understand that the information contained in this questionnaire is anonymous, as I am not supplying personal identifiers, and that this information will be destroyed after its use.

I agree

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Thanks for submitting! We look forward to meeting you for your scheduled appointment!

DONE