Mind & Mood Assessments

A brief and private tool to check in on your emotional well-being. It asks simple questions that screen for anxiety, depression, and how past experiences may be impacting your mood and daily life.
Parent's full name (if under the age of 18)

First NameLast Name
Your email*
example@example.com
Phone Number*

Using the provided prompt, respond to the questions below.

While you were growing up, during your first 18 years of life...
Did a parent or other adult in the household often or very often swear at you, insult you, put you down, or humiliate you? OR Act in a way that made you afraid that you might be physically hurt? *
Did a parent or other adult in the household often or very often push, grab, slap or throw something at you? OR Ever hit you so hard that you had marks or were injured? *
Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way? Or Attempt or actually have oral, anal, or vaginal intercourse with you? *
Did you often or very often feel that no one in your family loved your or thought you were important or special? OR Your family didn't look out for each other, feel close to each other, or support each other? *
Did you often or very often feel that you didn't have enough to eat, had to wear dirty clothes, and had no one to protect you? OR Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? *
Were your parents ever separated or divorced?*
Was your mother or stepmother often or very often pushed, grabbed, slapped, or had something thrown at her? OR Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? OR Ever repeatedly hit at least a few minutes or threatened with a gun or knife? *
Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?*
Was a household member depressed or mentally ill, or did a household member attempt suicide?*
Did a household member go to prison? *
ACEs Score:

	Not at all	Several Days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so figety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself

	Not at all	Several Days	More than half the days	Nearly every day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

A brief and private tool to check in on your emotional well-being. It asks simple questions that screen for anxiety, depression, and how past experiences may be impacting your mood and daily life.