Assessments & Measures CYW Adverse Childhood Experiences Questionnaire Teen (ACE-Q) Teen CYW ACE-Q Child (5-12) yo © Center for Youth Wellness 2015 Today's Date(Required) MM slash DD slash YYYY Child's Name(Required) First Last Gender(Required) Sexual Orientation Date of Birth(Required) MM slash DD slash YYYY Child's Age(Required) Child's Grade(Required) Your Name(Required) First Last Relationship to Child(Required) Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(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. Of the statements in Section 1, HOW MANY apply to your child? Write the total number in the box(Required) 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 unprotectedSection 2Of the statements in Section 2, HOW MANY apply to your child? Write the total number in the box(Required) 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) I agree to the privacy policy.When caring for an adolescent individual, please note that we believe: - that adolescents’ access to confidential health and mental health care is important for their health and well-being, while also recognizing the benefit of supportive parental involvement. - Pennsylvania state law states that children 14 and older have the legal right to give consent to health services and confidentiality must be maintained. - the adolescent will be offered an opportunity for assessment and interventions (counseling, etc.) separate from parents/guardians, but that the provider will encourage and assist the adolescent to involve parents or guardians in healthcare decisions. - confidentiality will be maintained in all situations except in certain situations and circumstances that create limitations on guaranteed confidentiality. For example: *unless there is written consent to disclose certain information. * there is a plan and intent to cause serious harm or death to yourself, and/or others * there is current or past suspicion or report of being abused physically, sexually, or emotionally; or that you have been abused in the past. *if there is a legal requirement or mandate *and to fulfil payment obligations (insurance, billing statements, etc.) What to Expect: Adolescent: Checking the box above indicates that you have reviewed the policies described and understand the limits to confidentiality. Parent/Guardian: Checking the box above indicates that you agree to respect your adolescent’s privacy and will refrain from requesting detailed information about my child's reports with my child. You understand that you will be provided with periodic updates about general progress, and/or may be asked to participate in sessions, activities, or programming with your child Although, you are aware that in the state of Pennsylvania, you have the legal right to request written records notes since your child is a minor, you agree NOT to request these records in order to respect the confidentiality of your adolescent’s treatment. You understand that you will be informed immediately about situations that could endanger your child. You understand that decision to breach confidentiality, in these circumstances, is up to the provider's professional judgment.EmailThis field is for validation purposes and should be left unchanged. Δ CYW Adverse Childhood Experiences Questionnaire Teen (ACE-Q) Teen CYW ACE-Q Teen (13-19 yo) © Center for Youth Wellness 2015 Today's Date(Required) MM slash DD slash YYYY Child's Name(Required) First Last Gender(Required) Sexual Orientation Date of Birth(Required) MM slash DD slash YYYY Child's Age(Required) Child's Grade(Required) Your Name(Required) First Last Relationship to Child(Required) Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(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. Of the statements in Section 1, HOW MANY apply to your child? Write the total number in the box(Required) 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 unprotectedSection 2Of the statements in Section 2, HOW MANY apply to your child? Write the total number in the box(Required) 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) I agree to the privacy policy.When caring for an adolescent individual, please note that we believe: - that adolescents’ access to confidential health and mental health care is important for their health and well-being, while also recognizing the benefit of supportive parental involvement. - Pennsylvania state law states that children 14 and older have the legal right to give consent to health services and confidentiality must be maintained. - the adolescent will be offered an opportunity for assessment and interventions (counseling, etc.) separate from parents/guardians, but that the provider will encourage and assist the adolescent to involve parents or guardians in healthcare decisions. - confidentiality will be maintained in all situations except in certain situations and circumstances that create limitations on guaranteed confidentiality. For example: *unless there is written consent to disclose certain information. * there is a plan and intent to cause serious harm or death to yourself, and/or others * there is current or past suspicion or report of being abused physically, sexually, or emotionally; or that you have been abused in the past. *if there is a legal requirement or mandate *and to fulfil payment obligations (insurance, billing statements, etc.) What to Expect: Adolescent: Checking the box above indicates that you have reviewed the policies described and understand the limits to confidentiality. Parent/Guardian: Checking the box above indicates that you agree to respect your adolescent’s privacy and will refrain from requesting detailed information about my child's reports with my child. You understand that you will be provided with periodic updates about general progress, and/or may be asked to participate in sessions, activities, or programming with your child Although, you are aware that in the state of Pennsylvania, you have the legal right to request written records notes since your child is a minor, you agree NOT to request these records in order to respect the confidentiality of your adolescent’s treatment. You understand that you will be informed immediately about situations that could endanger your child. You understand that decision to breach confidentiality, in these circumstances, is up to the provider's professional judgment.PhoneThis field is for validation purposes and should be left unchanged. Δ CYW Adverse Childhood Experiences Questionnaire Teen (ACE-Q) Teen CYW ACE-Q Teen Self-Report (13-19 yo) © Center for Youth Wellness 2015 Today's Date(Required) MM slash DD slash YYYY Child's Name(Required) First Last Gender(Required) Sexual Orientation Date of Birth(Required) MM slash DD slash YYYY Child's Age(Required) Child's Grade(Required) Your Name(Required) First Last Relationship to Child(Required) Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(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. Of the statements in Section 1, HOW MANY apply to your child? Write the total number in the box(Required) 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 unprotectedSection 2Of the statements in Section 2, HOW MANY apply to your child? Write the total number in the box(Required) 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) I agree to the privacy policy.When caring for an adolescent individual, please note that we believe: - that adolescents’ access to confidential health and mental health care is important for their health and well-being, while also recognizing the benefit of supportive parental involvement. - Pennsylvania state law states that children 14 and older have the legal right to give consent to health services and confidentiality must be maintained. - the adolescent will be offered an opportunity for assessment and interventions (counseling, etc.) separate from parents/guardians, but that the provider will encourage and assist the adolescent to involve parents or guardians in healthcare decisions. - confidentiality will be maintained in all situations except in certain situations and circumstances that create limitations on guaranteed confidentiality. For example: *unless there is written consent to disclose certain information. * there is a plan and intent to cause serious harm or death to yourself, and/or others * there is current or past suspicion or report of being abused physically, sexually, or emotionally; or that you have been abused in the past. *if there is a legal requirement or mandate *and to fulfil payment obligations (insurance, billing statements, etc.) What to Expect: Adolescent: Checking the box above indicates that you have reviewed the policies described and understand the limits to confidentiality. Parent/Guardian: Checking the box above indicates that you agree to respect your adolescent’s privacy and will refrain from requesting detailed information about my child's reports with my child. You understand that you will be provided with periodic updates about general progress, and/or may be asked to participate in sessions, activities, or programming with your child Although, you are aware that in the state of Pennsylvania, you have the legal right to request written records notes since your child is a minor, you agree NOT to request these records in order to respect the confidentiality of your adolescent’s treatment. You understand that you will be informed immediately about situations that could endanger your child. You understand that decision to breach confidentiality, in these circumstances, is up to the provider's professional judgment.CommentsThis field is for validation purposes and should be left unchanged. Δ
