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Adverse Childhood Experience Questionnaire
This Questionnaire will be asking some questions about you, specifically events in your childhood: specifically the first 18 years of your life. The information that you provide by answering these questions will allow me to better understand the challenges that you may have faced in your life and allow us to explore how these challenges may have impacted your life currently. 
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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?  *
Required
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?  *
Required
While you were growing up did a parent, step-parent, or another adult living in your home push, grab, shove, or slap you? *
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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? *
Required
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? *
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Attempt to have or actually have any type of sexual intercourse, oral, anal or vaginal with you? *
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There was someone in your life who helped you feel important or special. *
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Your family sometimes cut the size of meals or skipped meals because there was not enough money in the budget for food. *
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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? *
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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? *
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Did you live with anyone who was a problem drinker or alcoholic? *
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Did you live with anyone who used illegal street drugs or who abused prescription medications? *
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While you were growing up, did you live with anyone who was depressed or mentally ill? *
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Did you live with anyone who was suicidal? *
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Were your parents were ever separated or divorced? *
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Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility? *
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How often, if ever, did you see or hear someone being beaten up, stabbed, or shot in real life? *
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While you were growing up…How often did you feel that you were treated badly or unfairly because of your race or ethnicity? *
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Did you feel safe in your neighborhood? *
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Did you feel people in your neighborhood looked out for each other, stood up for each other, and could be trusted? *
Required
How often were you bullied by a peer or classmate? *
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Were you ever in foster care? *
Required
A copy of your responses will be emailed to the address you provided.
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