Ace Survey
This form will take approximately 5 minutes to complete..
Name:
*
Your First Name
Your Last Name
Email
example@example.com
Date
-
Month
-
Day
Year
Date
Care Manager's Name:
*
Your Care Manager's First Name
Your Care Manager's Last Name
When you were growing up, during the first 18 years of life:
Please fill in the appropriate information as best you can.
1. 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?
*
Yes
No
2. 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?
*
Yes
No
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?
*
Yes
No
4. 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, feel close to, or support each other?
*
Yes
No
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?
*
Yes
No
6. Were your parents ever separated or divorced?
*
Yes
No
7. Did your mother or stepmother: Often or very often pushed, grabbed, slapped or had something thrown at her? - or - Sometimes, often, or very often kicked, bitten, hit with a fist or hit with something hard? - or - Ever repeatedly hit at least a few minutes or threatened with a gun or knife?
*
Yes
No
8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
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Yes
No
9. Was a household member depressed or mentally ill, or did a household member attempt suicide?
*
Yes
No
10. Did a household member go to prison?
*
Yes
No
Ace Score = Total Number of "Yes":
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
Signature:
*
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: