ACE

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 the first 18 years of your 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 physically be hurt?

2. Did a parent or other adult in the household OFTEN push, grab, slap, or throw something at you? pr Ever hit you so hard that you had marks or were injured?

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? or Attempt or actually have oral, anal, or vaginal intercourse with you?

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 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?

6. Was a biological parent ever lost to you through divorce, abandonment, or other reason?

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? OR Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

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