ADVERSE CHILDHOOD EXPERIENCE (ACE) QUESTIONNAIRE
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Directions: Of the following questions, please type in “Yes” or “No” to the best of your recollection. If you answer "Yes" please describe, in as much detail as you are comfortable with, your experience and the persons associated. Please base all of your answers on events that occurred during the first 18 years of your life.

EMOTIONAL ABUSE:

NEGLECT:

PHYSICAL ABUSE:

SEXUAL ABUSE:

FAMILY DYSFUNCTION:

Directions: For this last question, please type in “Yes” or “No” to the best of your recollection. If you answer "Yes" please describe, in as much detail as you are comfortable with, your experiences and the persons associated. Please base your answer for any events that have occurred at any point in your life (as a child, teenager, or adult). 

By clicking "submit" below, I express understanding that the information I am providing will be utilized by a licensed mental health professional solely for the purposes of better understanding my experience as it currently relates to my symptoms. This information will be utilized, along with further information that will be gathered during my evaluation, in order to formulate a diagnosis. All of the information I have supplied is true to the best of my recollection, and I understand that any false information I provide may lead to misdiagnosis which may hinder services for myself. I understand that the information contained in this questionnaire is anonymous, as I am not supplying personal identifiers, and that this information will be destroyed after its use.

Disclaimer: The creators of the items in this collection hold the copyright to the individual works. NewLeaf Counseling of the River Valley, Inc. and its affiliate Stonehaven Behavioral Health & Wellness have exercised due diligence in attempting to contact the individual creators whenever possible. If you are a creator and would like to opt out of your work being displayed in our website, please contact stonehaven.clinic@gmail.com.

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