ACE's & Resilience Survey
This form was adapted from the Philadelphia ACE Study and will be used by the Carrie Mae Williams Center to gather much needed information about the needs of the citizens in urban neighborhoods across Tennessee. This information will be used to build support programs that have you in mind. If you are not from TN, you are still invited to take the survey however because your well-being is our priority. Please note that all information provided is confidential and and anonymous. It will only be used in anonymous reports to bring awareness to the needs of our community in order to secure much needed resources for you.
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Email *
Age Requirement.
In order to participate in this survey, you must be at least 18 years or older. Due to the sensitive nature of the information you are about to share, minors must be accompanied by an adult to have this survey completed. If The Carrie Mae Williams Center receives information that a submission has been provided by a minor without the consent of an adult, the submission will be stricken from data analysis immediately.
What is your birthday *
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Demographic Details
The first set of questions you will see pertain to your demographic profile, and will be used to analyze data from similar submissions as well as compare to against those who are different.
What city do you live in? *
What state do you live in? *
Please enter your zip code. *
Please describe your gender below. *
Which option below best describes your ethnicity? *
The following questions are designed to create a unique identifier that keeps track of your unique details without knowing your name.
What is your zodiac sign? *
Who is your favorite cartoon character? *
What are the lyrics to your favorite song? *
Would you be interested in having someone contact you to discuss your results confidentially and provide you with resources to help? *
First & Last Name
Please enter a reliable 10-digit number where The Center may contact you privately. Be sure to include your area code first.
Consent to use your data.
The information collected from you in this form is confidential and anonymous. It is also valuable to the organization because it gives us leverage to secure grants we can use to help you and others like you. Please consider allowing the Center to use your data in anonymous reports that help to inform the work we desire to do.
Do you give your consent to have the data you shared in this form be included in anonymous reports that help secure funding to help you and others like you? *
Community Safety
The next four questions ask about  events that happened during your childhood. This
information will allow us to better understand problems that may occur early in life, and may help others
in the future. This is a sensitive topic and some people may feel uncomfortable with these questions. At
the end of this section, I will give you a phone number for an organization that can provide information
and referral for these issues. Please keep in mind that you can ask me to skip any question you do not
want to answer. All questions refer to the time period before you were 18 years of age. Now, looking
back before you were 18 years of age---.

Did you live with anyone who was depressed, mentally ill, or suicidal? *
Did you live with anyone who was a problem drinker or alcoholic? *
Did you live with anyone who used illegal street drugs or who abused prescription medications? *
Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility? *
Were your parents separated or divorced? *
Before age 18, how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Do not include spanking. Would you say— *
How often did a parent or adult in your home ever swear at you, insult you, or put you down? *
 How often did anyone at least 5 years older than you or an adult, try to make you touch sexually? *
How often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up? *
How often did anyone at least 5 years older than you or an adult, ever touch you sexually? *
How often did anyone at least 5 years older than you or an adult, try to make you touch sexually? *
How often did anyone at least 5 years older than you or an adult, force you to have sex? *
RESILIENCE Questionnaire
Please circle the most accurate answer under each statement:

I believe that my mother loved me when I was little. *
I believe that my father loved me when I was little. *
When I was little, other people helped my mother and father take care of me and they seemed to love me. *
I’ve heard that when I was an infant someone in my family enjoyed playing with me, and I enjoyed it, too. *
When I was a child, there were relatives in my family who made me feel better if I was sad or worried. *
When I was a child, neighbors or my friends’ parents seemed to like me. *
When I was a child, teachers, coaches, youth leaders or ministers were there to help me. *
 Someone in my family cared about how I was doing in school. *
My family, neighbors and friends talked often about making our lives better. *
We had rules in our house and were expected to keep them. *
When I felt really bad, I could almost always find someone I trusted to talk to. *
As a youth, people noticed that I was capable and could get things done. *
 I was independent and a go-getter. *
I believed that life is what you make it. *
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