Adverse Childhood Experience (ACE) Questionnaire - Foundation for Foster ChildrenFoundation for Foster Children

Student Information

Youth Name*

Date

While you were growing up, during your first 18 years of life: 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?*

Yes
No

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?*

Yes
No

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

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?*

Yes
No

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?*

Yes
No

Were your parents ever separated or divorced?*

Yes
No

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?*

Yes
No

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

Yes
No

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

Yes
No

Did a household member go to prison?*

Yes
No

Adverse Childhood Experience (ACE) Assessment

Student Information