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Group ACE-Questionnaire

Please complete the form in its entirety. Your assigned therapist will review your account and make sure all needed documentation has been received prior to your appointment. Check your spam email for messages. Please contact us if you have any questions.

Full Name

Today's Date

Question 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 be physically hurt? *yesno

Did you answer, yes?Change this to 1 point if you answered yes. Don't change if answered no.

Question 2

Did a parent or other adult in the household often: Push, grab, slap, or throw something at you? Or Ever hit you so hard that you had marks or were injured? *yesno

Did you answer, yes?Change this to 1 point if you answered yes. Don't change if answered no.

Question 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? *yesno

Did you answer, yes?Change this to 1 point if you answered yes. Don't change if answered no.

Question 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? *yesno

Did you answer, yes?Change this to 1 point if you answered yes. Don't change if answered no.

Question 5

Did you 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? *yesno

Did you answer, yes?Change this to 1 point if you answered yes. Don't change if answered no.

Question 6

Were your parents ever separated or divorced? *yesno

Did you answer, yes?Change this to 1 point if you answered yes. Don't change if answered no.

Question 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? *yesno

Did you answer, yes?Change this to 1 point if you answered yes. Don't change if answered no.

Question 8

Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs? *yesno

Did you answer, yes?Change this to 1 point if you answered yes. Don't change if answered no.

Question 9

Was a household member depressed or mentally ill, or did a household member attempt suicide? *yesno

Did you answer, yes?Change this to 1 point if you answered yes. Don't change if answered no.

Question 10

Did a household member go to prison? *yesno

Did you answer, yes?Change this to 1 point if you answered yes. Don't change if answered no.

Your Total Score

Services

Individual Counseling

Couples Counseling

Family/Group Counseling

Grief/Loss Counseling

Anger Management

PTSD Treatment

Life Coaching

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Head Office

28800 7 Mile, Livonia, MI 48152

Call us

(248) 442-7300

Email us

kimhillery@yahoo.com