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Adverse Childhood Experience (ACE) Self-rating

O   A parent or other adult in the household would often swear at me, insult me, put me down, humiliate me, or act in a way that made me fear I would be physically hurt.

O   A parent or other adult in the household would often push, grab, slap, or throw something at me or would hit me so hard that I had marks or was injured.

O   A adult or person at least 5 years older than me touched or fondled me or had me touch their body in a sexual way or tried to or actually had oral, anal, or vaginal sex with me.

O   I often felt that no one in my family loved me or thought I was important or special or that my family didn't feel close or support or look out for each other. 

O   I often felt that I didn't have enough to eat, had to wear dirty clothes, and had no one to protect me or that my parents were too drunk or high to take care of me or take me to the doctor if I needed to go.

O   My parents were separated or divorced.

O   My mother was often pushed, grabbed, slapped, or had something thrown at her or sometimes kicked, bitten, hit with a fist or something hard, or ever repeatedly hit over at least a few minutes or threatened with a gun or knife.

O   I live with someone who was a problem drinker o alcoholic or who used street drugs.

O  A household member was depressed or mentally ill or attempted suicide.

O  A household member went to prison

                                   ********************************

____   How many of these types of Adverse Childhood Experiences did I have as a child up until age 18?

____   How many still upset me now? For help right now, here are some phone numbers:

          General Help line: 211

         Emergency Line:  911

         Mental Health Crisis Hot line:  1-888-568-1112

         Family Violence Hot Line:  1-800-799-SAFE (7233)

         Abused Women's Advocacy Project: 1-800-599-2927

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