Assessments & Measures

CYW Adverse Childhood Experiences Questionnaire Teen (ACE-Q) Teen CYW ACE-Q Child (5-12) yo

© Center for Youth Wellness 2015
MM slash DD slash YYYY
Child's Name(Required)
MM slash DD slash YYYY
Your Name(Required)
Address(Required)

Section 1

Many children experience stressful life events that can affect their health and wellbeing. The results from this questionnaire will assist your child’s provider in assessing their needs and determining guidance. Please read the statements below. Count the number of statements that apply to your child and write the total number in the box provided. Please DO NOT mark or indicate which specific statements apply to your child.
At any point since your child was born… ! Your child’s parents or guardians were separated or divorced ! Your child lived with a household member who served time in jail or prison ! Your child lived with a household member who was depressed, mentally ill or attempted suicide ! Your child saw or heard household members hurt or threaten to hurt each other ! A household member swore at, insulted, humiliated, or put down your child in a way that scared your child OR a household member acted in a way that made your child afraid that s/he might be physically hurt ! Someone touched your child’s private parts or asked them to touch that person’s private parts in a sexual way that was unwanted, against your child’s will, or made your child feel uncomfortable ! More than once, your child went without food, clothing, a place to live, or had no one to protect her/him ! Someone pushed, grabbed, slapped or threw something at your child OR your child was hit so hard that your child was injured or had marks ! Your child lived with someone who had a problem with drinking or using drugs ! Your child often felt unsupported, unloved and/or unprotected

Section 2

At any point since your child was born… ! Your child was in foster care ! Your child experienced harassment or bullying at school ! Your child lived with a parent or guardian who died ! Your child was separated from her/him primary caregiver through deportation or immigration ! Your child had a serious medical procedure or life-threatening illness ! Your child often saw or heard violence in the neighborhood or in her/his school neighborhood ! Your child was detained, arrested, or incarcerated ! Your child was often treated badly because of race, sexual orientation, place of birth, disability, or religion ! Your child experienced verbal or physical abuse or threats from a romantic partner (i.e. boyfriend or girlfriend)
Consent(Required)
This field is for validation purposes and should be left unchanged.

CYW Adverse Childhood Experiences Questionnaire Teen (ACE-Q) Teen CYW ACE-Q Teen (13-19 yo)

© Center for Youth Wellness 2015
MM slash DD slash YYYY
Child's Name(Required)
MM slash DD slash YYYY
Your Name(Required)
Address(Required)

Section 1

Many children experience stressful life events that can affect their health and wellbeing. The results from this questionnaire will assist your child’s provider in assessing their needs and determining guidance. Please read the statements below. Count the number of statements that apply to your child and write the total number in the box provided. Please DO NOT mark or indicate which specific statements apply to your child.
At any point since your child was born… ! Your child’s parents or guardians were separated or divorced ! Your child lived with a household member who served time in jail or prison ! Your child lived with a household member who was depressed, mentally ill or attempted suicide ! Your child saw or heard household members hurt or threaten to hurt each other ! A household member swore at, insulted, humiliated, or put down your child in a way that scared your child OR a household member acted in a way that made your child afraid that s/he might be physically hurt ! Someone touched your child’s private parts or asked them to touch that person’s private parts in a sexual way that was unwanted, against your child’s will, or made your child feel uncomfortable ! More than once, your child went without food, clothing, a place to live, or had no one to protect her/him ! Someone pushed, grabbed, slapped or threw something at your child OR your child was hit so hard that your child was injured or had marks ! Your child lived with someone who had a problem with drinking or using drugs ! Your child often felt unsupported, unloved and/or unprotected

Section 2

At any point since your child was born… ! Your child was in foster care ! Your child experienced harassment or bullying at school ! Your child lived with a parent or guardian who died ! Your child was separated from her/him primary caregiver through deportation or immigration ! Your child had a serious medical procedure or life-threatening illness ! Your child often saw or heard violence in the neighborhood or in her/his school neighborhood ! Your child was detained, arrested, or incarcerated ! Your child was often treated badly because of race, sexual orientation, place of birth, disability, or religion ! Your child experienced verbal or physical abuse or threats from a romantic partner (i.e. boyfriend or girlfriend)
Consent(Required)
This field is for validation purposes and should be left unchanged.

CYW Adverse Childhood Experiences Questionnaire Teen (ACE-Q) Teen CYW ACE-Q Teen Self-Report (13-19 yo)

© Center for Youth Wellness 2015
MM slash DD slash YYYY
Child's Name(Required)
MM slash DD slash YYYY
Your Name(Required)
Address(Required)

Section 1

Many children experience stressful life events that can affect their health and wellbeing. The results from this questionnaire will assist your child’s provider in assessing their needs and determining guidance. Please read the statements below. Count the number of statements that apply to your child and write the total number in the box provided. Please DO NOT mark or indicate which specific statements apply to your child.
At any point since your child was born… ! Your child’s parents or guardians were separated or divorced ! Your child lived with a household member who served time in jail or prison ! Your child lived with a household member who was depressed, mentally ill or attempted suicide ! Your child saw or heard household members hurt or threaten to hurt each other ! A household member swore at, insulted, humiliated, or put down your child in a way that scared your child OR a household member acted in a way that made your child afraid that s/he might be physically hurt ! Someone touched your child’s private parts or asked them to touch that person’s private parts in a sexual way that was unwanted, against your child’s will, or made your child feel uncomfortable ! More than once, your child went without food, clothing, a place to live, or had no one to protect her/him ! Someone pushed, grabbed, slapped or threw something at your child OR your child was hit so hard that your child was injured or had marks ! Your child lived with someone who had a problem with drinking or using drugs ! Your child often felt unsupported, unloved and/or unprotected

Section 2

At any point since your child was born… ! Your child was in foster care ! Your child experienced harassment or bullying at school ! Your child lived with a parent or guardian who died ! Your child was separated from her/him primary caregiver through deportation or immigration ! Your child had a serious medical procedure or life-threatening illness ! Your child often saw or heard violence in the neighborhood or in her/his school neighborhood ! Your child was detained, arrested, or incarcerated ! Your child was often treated badly because of race, sexual orientation, place of birth, disability, or religion ! Your child experienced verbal or physical abuse or threats from a romantic partner (i.e. boyfriend or girlfriend)
Consent(Required)
This field is for validation purposes and should be left unchanged.