Adverse Childhood Experiences (ACEs) Assessment

Client name: Sarah Johnson 1. Did you often feel that you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect or care for you? [ ] 2. Did you lose a parent through divorce, abandonment, death, or another reason? [X] 3. Did you live with someone who was depressed, mentally ill, or who attempted suicide? [X] 4. Did you live with someone 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 one another? [X] 6. Did you live with someone who went to jail or prison? [ ] 7. Did a parent or adult in your home frequently swear at you, insult you, or belittle you? [X] 8. Did a parent or adult in your home ever hit, beat, kick, or physically harm you? [ ] 9. Did you often feel that no one in your family loved you or thought you were special? [X] 10. Did you experience any unwanted sexual contact (e.g., fondling, or oral/anal/vaginal intercourse/penetration)? [ ] Total ACE Score: 5 Follow-Up Questions: - Do you feel that these experiences have impacted your overall health? - Not Much [ ] - Some [X] - A Lot [ ]