Adverse Childhood Experiences (ACEs) Assessment. Survivors of Narcissistic Abuse recovery therapist. Mark Zauss - MARK ZAUSS - THERAPY

MARK ZAUSS - THERAPY

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Adverse Childhood Experiences (ACEs) Assessment

Adverse Childhood Experiences (ACEs) Assessment

Adverse Childhood Experiences (ACEs) are traumatic events that occur during childhood (0-17 years). These experiences can have a significant impact on a person's physical, mental, and social health throughout their life.

Our relationships and experiences—even those in childhood—can affect our health and well-being. Difficult childhood experiences are very common. Please tell us whether you have had any of the experiences listed below, as they may be affecting your health today or may affect your health in the future. This information will help you and your provider better understand how to work together to support your health and well-being.

Adverse Childhood Experiences (ACEs)

Instructions: Below is a list of 10 categories of Adverse Childhood Experiences (ACEs). From the list below, please place a checkmark next to each ACE category that you experienced prior to your 18th birthday. Then, please add up the number of categories of ACEs you experienced and put the total number at the bottom.

* Indicates required field

Name *

First

Last

Email *

1. Did you feel that you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you?

Chose one *

Yes No Not Sure

2. Did you lose a parent through divorce, abandonment, death, or other reason?

Choose One *

Yes No Not Sure

3. Did you live with anyone who was depressed, mentally ill, or attempted suicide?

Choose One *

Yes No Not Sure

4.Did you live with anyone who had a problem with drinking or using drugs, includingprescription drugs?

Choose One *

Yes No Maybe

5. Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other?

Choose One *

Yes No Maybe

6. Did you live with anyone who went to jail or prison?

Choose One *

Yes No Not Sure

7. Did a parent or adult in your home ever swear at you, insult you, or put you down?*

Choose One *

Yes No Maybe

8. Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?

Choose One *

Yes No Maybe

9. Did you feel that no one in your family loved you or thought you were special?

Choose One *

Yes No Maybe

10.Did you experience unwanted sexual contact (such as fondling or oral/anal/vaginalintercourse/penetration)?

Choose One *

Yes No Maybe

Your ACE score is the total number of checked YES responses

Select One *

Do you believe that these experiences have affected your health?

Choose one *

Not Much Some A Lot

Please click the submit button below to send the results to Mark Zauss

Submit

Home
Credentials
ADHD
OCD
Anxiety
AUD
Bipolar
Autism
CBT and DBT
Narcissistic Abuse
Post-Concussion Syndrome
Insurance
Contact