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Adverse Childhood Experiences (ACEs) Questionnaire

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Introduction
By completing this form, we will be able to better understand any traumatic experiences that may be affecting your mental and emotional well-being and standing in the way of your happiness. This assessment is not a diagnosis but rather a guide that provides valuable insights to help refine our therapeutic approach and create a customized plan tailored to your most important needs and goals.
The Adverse Childhood Experiences (ACEs) questionnaire consists of 10 questions that help identify potentially traumatic events that occurred before the age of 18. The higher the score, the greater the cumulative impact of adverse experiences, which can increase the risk of developing mental, emotional, and physical health challenges later in life. Each question corresponds to one type of adverse experience, and the total number of positive answers gives the ACE score.
However, it’s important to remember that:
- Not everyone with a high ACEs score will develop difficulties: Factors like resilience, supportive relationships, and protective environments can mitigate the effects.
- Context matters: The nature, duration, and severity of the experiences—as well as individual coping strategies—can influence how someone is affected.
- It’s a screening tool, not a diagnosis: The score alone doesn’t capture the full picture of someone’s life or the strengths they have developed despite adversity.
Please take your time with each question and answer as honestly and openly as you can. There are no right or wrong answers—just your experience, which is valuable and important.
I look forward to our time together.
Warmly,
Monika
Monika Grace, CCTP-II
Integrative Somatic Psychotherapist, Trauma Specialist, EMDR, IFS, SE, PSYCH-K
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What is your full name?

What is your email?

Where are you located (city)?

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For each of the following questions, answer Yes or No.

Yes = 1 point
No = 0 points.
Add up your points at the end to get your ACE score.

1. Did a parent or other adult in the household often or very 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?

It's not mandatory to share who this feedback is coming from, but it can help to ask some follow-up questions if necessary.
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2. Did a parent or other adult in the household often or very often... push, grab, slap, or throw something at you? Or ever hit you so hard that you had marks or were injured?

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?

4. Did you often or very 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?

5. Did you often or very 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?

6. Were your parents ever separated or divorced?

7. Was your mother or stepmother: often or very often pushed, grabbed, slapped, or had something thrown at her? Or sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? Or ever repeatedly hit at least a few minutes or threatened with a gun or knife?

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

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

10. Did a household member go to prison?

Is there anything else from your past that has had a profound impact on you and that you’d like to share?

Thank you for answering the above questions. We appreciate your time and honesty. We will discuss your results during your sessions and use these insights to design a customized healing plan that best suits your goals and needs.
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