Adverse Childhood Experiences (ACEs) Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Our childhood relationships and experiences can affect our health and well-being. ACEs are very common! According to data collected from adults across all 50 states between 2011 and 2020: 64% reported experiencing at least ONE type of ACE and 17% reported experiencing FOUR or more types of ACEs (cdc.com).

Please tell us whether you have had any of the experiences listed below. This information will help you better understand how to support your health and well-being.

Instructions: Below is a list of the 4 categories of Adverse Childhood Experiences (ACEs). From the list below, please answer "yes" or "no" to any experience prior to your 18th birthday.

Email *

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms