Referral Form | Chosen Care, Inc.

UCLA Assessment

This form will take approximately 5 minutes to complete. Form to be completed by parent/ caregiver. Pediatric ACEs and Related Life Events Screener.
1.How often do you feel that you are in tune with the people around you?*

NeverRarelySometimesOften
2. How often do you feel that you lack companionship?*

NeverRarelySometimesOften
3. How often do you feel that there is no one you can turn to?*

NeverRarelySometimesOften
4. How often do you feel alone?*

NeverRarelySometimesOften
5. How often do you feel part of a group of friends?*

NeverRarelySometimesOften
6. How often do you feel that you have a lot in common with the people around you?*

NeverRarelySometimesOften
7. How often do you feel that you are no longer close to anyone?*

NeverRarelySometimesOften
8. How often do you feel that your interests and ideas are not shared by those around you?*

NeverRarelySometimesOften
9. How often do you feel outgoing and friendly?*

NeverRarelySometimesOften
10. How often do you feel close to people?*

NeverRarelySometimesOften
11. How often do you feel left out?*

NeverRarelySometimesOften
12. How often do you feel that your relationships with others are not meaningful?*

NeverRarelySometimesOften
13. How often do you feel that no one really knows you well?*

NeverRarelySometimesOften
14. How often do you feel isolated from others?*

NeverRarelySometimesOften
15. How often do you feel you can find companionship when you want it?*

NeverRarelySometimesOften
16. How often do you feel that there are people who really understand you?*

NeverRarelySometimesOften
17. How often do you feel shy?*

NeverRarelySometimesOften
18. How often do you feel that people are around you but not with you?*

NeverRarelySometimesOften
19. How often do you feel that there are people you can talk to?*

NeverRarelySometimesOften
20. How often do you feel that there are people you can turn to?*

NeverRarelySometimesOften
Signature:*
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UCLA Assessment