Teen Pearl Survey
This form will take approximately 5 minutes to complete. Form to be completed by the teen. Pediatric ACEs and Related Life Events Screener.
Child's Name
*
Child's First Name
Child's Last Name
Parent/Caregiver Name:
*
Parent/Caregiver First Name
Parent/Caregiver Last Name
E-mail
*
example@example.com
Date
-
Month
-
Day
Year
Date
Parent Coach's Name:
*
Your Parent Coach's First Name
Your Parent Coach's Last Name
At any point in time since you were born, have you seen or been present when the following experiences happened? Please include past and present experiences.
Please note, that some questions have more than one part separated by “OR.” If any part of the question is answered “Yes,” then the answer to the entire question is “Yes.”
Part 1
Please check "Yes" where it applies.
1. Have you ever lived with a parent/caregiver who went to jail/prison?
*
Yes
No
2. Have you ever felt unsupported, unloved and/or unprotected?
*
Yes
No
3. Have you ever lived with a parent/caregiver who had mental health issues? (for example, depression,schizophrenia, bipolar disorder, PTSD, or an anxiety disorder)
*
Yes
No
4. Has a parent/caregiver ever insulted, humiliated, - or - put you down?
*
Yes
No
5. Has your biological parent or any caregiver ever had, or currently has a problem with too much alcohol,street drugs or prescription medications use?
*
Yes
No
6. Have you ever lacked appropriate care by any caregiver? (for example, not being protected from unsafesituations, or not being cared for when sick or injured even when the resources were available)
*
Yes
No
7. Have you ever seen or heard a parent/caregiver being screamed at, sworn at, insulted or humiliated by another adult? Or have you ever seen or heard a parent/caregiver being slapped, kicked, punched beaten up or hurt with a weapon?
*
Yes
No
8. Has any adult in the household often or very often pushed, grabbed, slapped or thrown something at you? - or - has any adult in the household ever hit you so hard that you had marks or were injured? - or - has any adult in the household ever threatened you or acted in a way that made you afraid that you might be hurt?
*
Yes
No
9. Have you ever experienced sexual abuse? (for example, has anyone touched you or asked you to touch that person in a way that was unwanted, - or - made you feel uncomfortable, - or - anyone ever attempted or actuallyhad oral, anal, or vaginal sex with you)
*
Yes
No
10. Have there ever been significant changes in the relationship status of your caregiver(s)? (for example, a parent/caregiver got divorce or separated, romantic partner moved in or out)
*
Yes
No
How many “Yes” did you answer in Part 1?:
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
Part 2
Please check "Yes" where it applies.
1. Have you ever seen, heard, or been a victim of violence in your neighborhood, community or school? (for example, targeted bullying, assault or other violent actions, war or terrorism)
*
Yes
No
2. Have you experienced discrimination? (for example, being hassled or made to feel inferior or excluded because of their race, ethnicity, gender identity, sexual orientation, religion, learning differences, or disabilities)
*
Yes
No
3. Have you ever had problems with housing? (for example, being homeless, not having a stable place to live,moved more than two times in a six-month period, faced eviction or foreclosure, or had to live with multiplefamilies or family members)
*
Yes
No
4. Have you ever worried that you did not have enough food to eat or that food would run out before you - or - your parent/caregiver could buy more?
*
Yes
No
5. Have you ever been separated from your parent or caregiver due to foster care, or immigration?
*
Yes
No
6. Have you ever lived with a parent/caregiver who had a serious physical illness or disability?
*
Yes
No
7. Have you ever lived with a parent or caregiver who died?
*
Yes
No
8. Have you ever been detained, arrested or incarcerated?
*
Yes
No
9.Have you ever experienced verbal or physical abuse or threats from a romantic partner(s)? (for example, a boyfriend or girlfriend)
*
Yes
No
How many “Yes” did you answer in Part 2?:
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
Signature:
*
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: