ACEs Survey 15 Questions

1

Is this your first time taking this version or any version of the ACE quiz?* This field is required.By completing this survey, you are acknowledging the terms of use listed here: https://www.acesmatter.org/termsofuse.html

YES, this is my first time taking the quiz

No, I have taken the quiz before

2

Please enter your primary zip code... * This field is required.

US or Country Postal code

3

I have read the information above and understand that ACEs Matter provides this information for educational purposes only.If you experience strong emotions when recalling your own experiences or sadness/regret about the experiences of your children or loved ones and need immediate support and resources, the National Suicide Prevention Lifeline is available 24/7 at 1-800-273-8255.

YES, I agree to proceed

4

1. Before your 18th birthday, did you see or hear a parent or household member being yelled at, screamed at, beat up, cursed at, insulted or humiliated?* This field is required.

YES

NO

5

2. Before your 18th birthday, did you live with or witness a household member abuse or misuse alcohol, prescription drugs, or illegal drugs?* This field is required.

YES

NO

6

3. Before your 18th birthday, did you live with a household member who was depressed, mentally ill, or suicidal?* This field is required.

YES

NO

7

4. Before your 18th birthday, did you live with or witness a household member be arrested, sent to prison, or get deported?* This field is required.

YES

NO

8

5. Before your 18th birthday, were your parents ever separated, divorced, or did either of them pass away?* This field is required.

YES

NO

9

Before the age of 18, did your parents or guardians often seem too busy or unavailable to meet your emotional needs or to make you feel special?* This field is required.

YES

NO

10

7. Before your 18th birthday, did you go without a meal, adequate food, or clean clothes?* This field is required.

YES

NO

11

8. Before your 18th birthday, did a parent, guardian, or other household member yell, scream, curse, insult, or humiliate you?* This field is required.

YES

NO

12

9. Before your 18th birthday, did a parent, guardian, or other household member spank, slap, kick, punch or injure you in a way that left bruises or scars?* This field is required.

YES

NO

13

10. Before your 18th birthday, did someone touch, fondle, or make you perform sexual acts that made you feel uncomfortable?* This field is required.

YES

NO

14

11. Before your 18th birthday, did you grow up in a community where illegal activity and violence were common?* This field is required.

YES

NO

15

12. Before your 18th birthday, did someone often or very often bully you?* This field is required.

YES

NO

16

13. Before your 18th birthday, did you experience poverty or live in a poverty-stricken neighborhood?* This field is required.

YES

NO

17

14. Growing up, were you treated badly, unfairly, or differently because of your race, skin tone, or ethnicity?* This field is required.

YES

NO

18

15. Before your 18th birthday, did you experience: homelessness, foster care placement, or psychiatric residence placement?* This field is required.

YES

NO

19

What email address should we send the results to?* This field is required.

example@example.com

20

What is your first name (or initials)?* This field is required.

21

Your ACE Score TotalAn ACE score is a number that tells a story - you are on the right path!

22

Would you like to speak to someone about next steps?skip this question if not

Please enter a valid phone number.