Adverse Childhood Experiences

Instructions: Below is a list of 10 categories of Adverse Childhood Experiences (ACEs). From the list

below, please place a checkmark next to each ACE category that you experienced prior to your 18th

birthday. Then, please add up the number of categories of ACEs you experienced and put the total

number at the bottom.

1. Did you feel that you didn’t have enough to eat, had to wear dirty clothes, or

had no one to protect or take care of you?

2. Did you lose a parent through divorce, abandonment, death, or other reason?

3. Did you live with anyone who was depressed, mentally ill, or attempted suicide?

4. Did you live with anyone who had a problem with drinking or using drugs, including

prescription drugs?

5. Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other?

6. Did you live with anyone who went to jail or prison?

7. Did a parent or adult in your home ever swear at you, insult you, or put you down?

8. Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?

9. Did you feel that no one in your family loved you or thought you were special?

10. Did you experience unwanted sexual contact (such as fondling or oral/anal/vaginal

intercourse/penetration)?

*Your ACE score is the total number of checked responses