Personal Assessment Questionnaire

Adverse Childhood Experence - Questions

TICN:  A few words about the Adverse Childhood Experience (ACE) Questionnaire

The Trauma Checklist for Youth addresses 10 types of childhood trauma measured in the ACE Study.  Five are personal — physical abuse, verbal abuse, sexual abuse, physical neglect, and emotional neglect. Five are related to other family members: a parent who’s an alcoholic, a mother who’s a victim of domestic violence, a family member in jail, a family member diagnosed with a mental illness, and the disappearance of a parent through divorce, death or abandonment.

You can bring your results to a trauma informed mental health professional for help with interpretation, scoring, and treatment.  Please print a copy upon completion!

Adverse Childhood Experience Questionnaire:   Please be assured your complete confidentiality is our promise !

If you answer "Yes" to any question, please selet the "Yes",  otherwise  select "No"  !

Please complete all questions !

/ /
Male
Female
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

* Required

** You can bring your results to a trauma informed mental health professional for help with interpretation, scoring, and treatment.   Please print a copy upon completion!